All right. Let's get started so we can remain on time. Welcome to this session discussing some complex topics in rotator cuff surgery. We're going to start with a couple scientific papers. I'd like to call up Haley McKissick to the podium. She's going to speak on comparing outcomes between trapezial transfer and SCR for massive irreparable rotator cuff tears. Hi, everyone. Thanks for having me. My name is Haley McKissick. I'm a resident at Emory. I'm going to be talking today about arthroscopic-assisted lower trap tendon transfer versus SCR for massive cuff tears. All of our disclosures are visible on the AOS website. We have none that are pertinent to this study. So as a lot of us know, massive irreparable cuff tears are very difficult to treat, especially in patients who are young, active, and who aren't good candidates for arthroplasty. Superior capsular reconstruction, or SCR, and lower trap tendon transfer, or LTT, are both viable options. The fundamental principle of SCR is restoration of static glenohumeral stability. So when the superior capsular is restored, the position of the glenohumeral joint is maintained and the patient can actively move their shoulder. LTT, on the other hand, provides dynamic stability. So when the lower trap is transferred to the greater tuberosity, Achilles' algraft is used for length augmentation. And then the line of pull of this transfer replicates that of the infraspinatus, and this restores the posterior axial force couple that's disrupted in massive cuff tears. There's no established algorithm currently or gold standard for when to use what procedure for massive irreparable cuff tears. At our institution, anecdotally, we've used lower trap for patients who have poor muscle quality or a lot of fatty infiltration, and the idea behind that being that the good muscle from the tendon transfer would replace the poor muscle that has degenerated in the patient. So the purpose of this study was to compare the post-op outcomes and failure rates in patients undergoing LTT versus SCR. And then further, we stratified by fatty infiltration of the rotator cuff. This is a retrospective institutional study. We included all patients who underwent SCR or LTT for massive irreparable cuff tears. We excluded any patients who had less than 12 months of follow-up, Hamada scores of greater than or equal to four, and any revision, capsular reconstructions, or tendon transfers. The outcomes we assessed included patient-reported outcomes, as well as active range of motion, failure rates, and revision rates. And then the analysis that we did, we looked at all SCR patients versus all LTT patients, and then stratified by Goutelier classification of the cuff, using zero or one as a preserved muscle category with little to no fatty infiltration, and two, three, or four as considered high fatty infiltration, poor muscle quality, and atrophy. So this is our demographics table. We had 45 total LTT patients, 36 SCR patients. Overall, at baseline, they were pretty similar across the board. The main differences that we wanted to point out were that more patients in the SCR group had had prior rotator cuff repairs attempted. Essentially all lower trap patients had higher Goutelier scores, and that's just kind of by the nature of our patient selection at Emory that I had touched on previously. Subscap repairs were similar between the two groups, and also average follow-up was more than two years in each group. This table shows comparison of outcomes between all LTT and all SCR patients, regardless of Goutelier classification. So patients who underwent SCR had significantly worse range of motion in all planes except internal rotation, and they also had worse subjective shoulder scores, increased pain scores, and significantly higher failure rates. But when we'd stratified patients by their fatty infiltration of the cuff, the results were different. So looking first at the blue column on the left, this shows the outcomes for patients who had SCR but who had preserved muscle quality. The green column is SCR for patients who had poor muscle quality, and you can see that when we compare these two groups, there's some pretty substantial differences. Patients who had preserved muscle overall had superior outcomes when it came to patient reported outcomes, range of motion of the shoulder, and failure in revision rates. When we compared SCR patients who had preserved muscle to LTT patients, who again essentially had all poor muscle quality, the outcomes were similar. So there was no statistical difference between these two groups. We did run a statistical analysis. The p-values are omitted from this chart just for conciseness sake, but the analysis showed that patient reported outcomes, range of motion, and failure in revision rates were comparable. On the other hand, when we look at patients who had an SCR and who had high fatty infiltration or poor muscle quality, they performed significantly worse than the LTT patients who had poor muscle quality. This included with patient reported outcome scores again, and then failure in revision rates in the LTT group were significantly lower at 9% in LTT versus 65% in SCR, and 7% in LTT versus 40% in SCR. And again, range of motion in all planes was superior in the LTT patients compared to the SCR patients. So in some, patients who had an SCR with preserved muscle quality had better outcomes than patients who had SCR with poor muscle quality, and then patients who had an SCR with poor muscle quality did significantly worse than LTT. There were some limitations to this study. Their sample sizes were relatively small. It's also a retrospective study, and then it was a single institution study where the surgeon who performs our lower trap tendon transfers has a lot of experience, and surgeon experience can definitely play a role. But in conclusion, patients who have good muscle, good cuff muscle, but tendon deficiency, we recommend that they have an SCR. But in patients who have Goutelier grade 2 or higher fatty infiltration of the cuff, this is a relative indication for LTT and a relative contraindication for SCR. Thank you. Our next speaker is Steven Marcaccio. On incidental teres minor atrophy in patients undergoing arthroscopic rotator cuff repair of the supraspinatus occurs frequently and is associated with worst postoperative outcomes without higher failure rates. Thank you. Good morning. My name is Steve Marcaccio. I'm a sports medicine fellow at the University of Pittsburgh. I'd like to thank the selection committee for the opportunity to present our work where we found that the incidental teres minor fatty infiltration occurs frequently in those undergoing rotator cuff repair of the supraspinatus tendon, and we found it to be associated with worst postoperative outcomes despite unchanged failure rates. I'd also like to thank my coauthors listed below, without whom this project would not be possible. While we have no disclosures relevant to this presentation, all of our disclosures can be found on the AOSSM website. As we know, fatty infiltration of the supraspinatus and infraspinatus muscles has been associated with worst postoperative outcomes following rotator cuff repair. However, when focusing on isolated fatty infiltration of the teres minor, this is a fairly rare phenomenon, as reported incidents varies across literature from 1 to 6 percent in the absence of full thickness pathologies. The impact of this fatty infiltration is subject to debate. Looking at the current literature, maybe unsurprisingly, there isn't a ton out there, and this 2020 paper by Dr. Sarkeesian and all of the authors found an incidence rate of approximately 50 percent and found that those with fatty infiltration had significant lower postoperative functional outcome scores when compared to those without. However, this 2016 study by Dr. Kim et al. retrospectively reviewed over 800 patients undergoing arthroscopic rotator cuff repair and found an incidence rate of 6.3 percent. They did not find a difference in outcomes with those with depreciated teres minor fatty infiltration. Therefore, our study's aims were twofold. First, we focused on identifying the incidence of teres minor fatty infiltration in patients undergoing arthroscopic rotator cuff repairs isolated to the supraspinatus and infraspinatus tendon. Second, we assessed the impact of the fatty infiltration on postoperative outcomes and failures. We hypothesized that those patients undergoing rotator cuff repair of the supraspinatus and infraspinatus tendon have a relatively high incidence of fatty infiltration of the teres minor, and second, that the presence of this fatty infiltration would correlate with worse postoperative reported outcomes and higher failure and revision rates. We performed a retrospective review of patients with partial and full thickness supraspinatus and or infraspinatus tendon teres undergoing arthroscopic double row transosseous opponent repairs over a six-year period. Exclusion criteria included fall of less than one year, revision repairs, inaccessible MRIs, non-double row repairs, and associated subscapularis repairs. We classified the teres minor fatty infiltration according to the Fuchs et al. modification of the Goutelier classification utilizing MRI rating fatty infiltration on a scale of zero to four on the sagittal cut, scapular wide view using a T1-weighted MRI. The outcomes of interest included objective shoulder function, including documented range of motion and strength measurements, and patient-reported outcomes, including the VAS, SSV, and ASCS values. Failures were defined as symptomatic retear and postoperative MRI, the need for revision surgery with previous rotator cuff repair, or conversion to a reverse total shoulder arthroplasty. The surgical technique was an arthroscopic transosseous equivalent double row repair with either knotted or knotless constructs. All patients followed the same postoperative protocol with sling immobilization followed by passive range of motion and pendulums initiated at 10 days, active range of motion at 6 weeks, and then strengthening beaming at 12 weeks, with most patients resuming full activities around the 6-month mark. In total, 106 patients met our inclusion criteria with demographics shown here. The full thickness and partial thickness groups differ only in age, but did not differ in gender, BMI, or mean follow-up. When we look at the incidence, we found that 53% of patients had some level of teres minor fatty infiltration with similar rates between both partial and full thickness teres. We chose to stratify the groups as no fatty infiltration versus any level of fatty infiltration due to the low level of grades 3 and 4 infiltration that was appreciated, which is consistent with previous literature. Between these two groups, rotator cuff teres size, severity of supraspinatus fatty infiltration, and severity of infraspinatus fatty infiltration did not differ. We additionally stratified by partial and full thickness teres. Interestingly, we found that mental and physical PROMIS scores were statistically significantly different between the groups in the partial thickness teres cohort, while objective functional measurements did not differ. Further, when we look at the full thickness teres cohort, we found a statistically significant difference in physical PROMIS scores only, no difference in objective functional measurements. Now looking at additional patient-reported outcomes, the full thickness teres cohort was found to have significantly different ASES, PROFI, and SSV values, with the ASES meeting the MCID criteria for associated repair. Finally, neither partial or full thickness teres differed between groups with regards to failure or revision rates. So our study is certainly not free of limitations. First, the only two types of arthroscopic repair techniques utilized, while commonly utilized, may limit the generalizability of this study. Second, the minimal follow-up time of one year may create a selection bias, as patients experience excellent outcomes as early as six months postoperatively may not follow up past one year, as those having poor outcomes may continue to follow beyond that point. Further, without pre-op and postoperative EMG data, we don't have a specific source of the appreciated infiltration, which brings the question of whether this was incidental finding associated with pathology versus a sign of something more pathologic going on, such as compression of the axillary nerve in the quadrilateral space. And finally, we did not correlate the chronicity of the teres with the presence of this infiltration, which is something that we are working on for future projects. For example, in the setting of a chronic tere, patients may be compensating well and may have minimal atrophy or infiltration versus a more acute tere. So in conclusion, we found that the teres minor fatty infiltration was present in over 50% of patients undergoing rotator cuff repairs of the supraspinatus and or infraspinatus tendons. The presence of this fatty infiltration impacted patient-reported outcomes in full-thickness rotator cuff repairs, while partial-thickness teres demonstrated less effect on outcomes, with no appreciated difference in failure or revision rates. Identification of these patients preoperatively for informed counseling and also to develop strategies to optimize the patient's outcome may be valuable to help improve these outcomes. With that, I thank you for your time. So we're going to have a Q&A, if you guys have any questions, please step up to the microphones. Haley, I'd like to start off with a couple questions for you. I think inclusion criteria are very important when we're trying to figure out the differences between these types of big salvage procedures. You didn't say anything about active forward elevation. Were these patients able to forward elevate past 90 degrees? Were there any pseudo-paralytics in this group? There were no pseudo-paralytics in this group. There were patients that had range of motion that was limited by pain, but none that were to the point that they weren't able to forward elevate at all. They had some preserved motion. And was there any ER lag in any of them? Some did have ER lag. We didn't incorporate that into the statistical analysis, but there were some patients that had ER lag at baseline. I couldn't tell you the exact number. And one of the advantages of the LTT is that it is dynamic. Did you notice any strength differences that the LTT group have better strength after surgery compared to the SCR group? So we looked at strength, but we had limited numbers in the strength assessments. And so we noticed subjectively that there was an increase in strength, but it was tough to incorporate that into a statistical analysis just because we had a limited kind of data set. So Haley, one other question. It seemed like you grouped the Goutelier groups together for SUPRA and INFRA. What do you do with the patient that has isolated SUPRA disease but maintained infraspinatus? Do they fall into the SCR LAT transfer, or could you do either? So we did look at also, in addition to this, this was patients who had fatty infiltration of the infraspinatus was what I showed here. We did also assess patients who had either SUPRA or infraspinatus fatty infiltration, and we took the higher of the two values. And the results were the same. So even in patients who did have isolated SUPRA fatty infiltration. So I would say that the results of that study would apply to either. I think in patients who have just isolated poor muscle quality of the supraspinatus, you can still say that a lower trapped tendon transfer would be better for them. Just to piggyback off that, why do you think that matters? What's your theory behind that? Because both of the procedures bypass the SUPRA and the INFRA. You're not connecting to that muscle. So why does it matter? Why do you think they do worse? I don't have a great answer for that. I think it has to do probably just overall with the synergistic motion of the shoulder and being able to potentially compensate with the transfer after you have the new pull. But I don't, I'm not entirely sure. I have a couple more, sorry. The Woodmass article on SCR showed that women do worse than men with SCR, and you had way more women in the SCR group. Do you think that skewed the results at all, or do you have any thoughts on that? It could have potentially, but we did do a regression analysis where regardless, it didn't make a difference. So I think it could make a difference, but. Okay, thanks. Steve, who actually reviewed the MRIs? Was it the fellows? Was it Dr. Albert Lin? Was it the radiologists? Was there two of them? How did you grade, who graded these? It was two fellows and Dr. Lin as well. I'm sorry? It was two fellows and two of our faculty, the attending surgeons in the group. Steve, one last question. You know, in your group that had atrophy of the teres, your overall ASES score outcome was 63, which seemed really low to me. Do you think that that's really due to the trapezius alone, excuse me, to the teres minor alone, or do you think there was something else going on in that group? Because overall, for a large group, that just seems like a low number that's not consistent with what we see in larger groups in the literature. Yeah, we talked about that. I think it's probably something else addition to that. It's very tough with this type of study to identify the teres minor as the sole cause of that outcome. So my guess is that there is something more going on with that. But our patients were fairly well matched prior to the OR, but we don't really have a great answer for that. Is Dr. Albert addressing these in any way when he sees the teres minors atrophy, their quadriangular space release or something of that kind? Not necessarily a quadriangular space release, but really focusing on maximizing their prehab based on his wait time before surgery. Thanks, guys, appreciate it. Our next speaker is Grant Jones, he's going to give us technical pearls. All the pro tips to get the arthroscopic repair right. Okay. All right. There it is, okay. Thank you, Rafi. So I'm going to talk about my technique for addressing large rotator cuff tears. Just some basic things that I like to do. And is it advancing? Oh, that, okay. It's locked. Nope. Oh. That was weird. Okay. Okay. Sorry about that. All right, so these are my disclosures. So the key to repairing these tears are recognizing the tear pattern. If you get the tear pattern right, you're going to get a tension-free repair and you're going to get a better outcome in terms of structural and clinical outcomes. So this is a nice study looking at rotator cuff tear patterns and what they look like on an MRI scan and what you see arthroscopically. So those kind of short, wide type tears are going to be more crescent tears where the width is greater than the length. And if you see on the MRI scan that the tear is greater lengthwise than widthwise, then you're looking at more of a U-type or L-type type tear. And here's some typical MRI scans we see here. It's a coronal view of one of those L-type tears that's retracted in the posterior medial direction. So you see tendon more posteriorly. On the sagittal view here, you can see that tendon on the right here hanging out more posteriorly. So that's one we're going to reduce kind of anterior or lateral when we do a reduction. This is what this type of tear looks like arthroscopically. So it's pulled posterior medial. Again, we're going to have to do some releases here. But when we pull this anterior, that's going to get our best repair versus those type of tears where the tear is more retracted in the anterior medial direction. So you see more tendon anteriorly and it starts disappearing on the coronal as you go posteriorly. And you can see on the sagittal view here, the tendon is more anterior, which is to the right. And you lose it posteriorly. And this is what we see arthroscopically. So that's a tendon tear. So you want to take that apex. You want to bring that posterior or lateral and reduce it that way. If you try to reduce it more straight, you're going to get more tension on your repair. And this is a typical large crescent type tear we see here where the retraction is kind of symmetric as you move from anterior to posterior on the coronal cut as well as the sagittal cut here. And this is what we see arthroscopically. So that nice crescent tear that you were going to pour directly over. Then you have these more complex type tears here. So you have an anterior leaf here that is retracted anterior medial and want to reduce that posterior lateral. Then you have that posterior leaf that is retracted posterior medial and you want to bring that up anteriorly. So it's important to recognize that tear pattern. And then you have your u-type tears that you're going to do more of a marginal convergence So so the first thing we do is we kind of assess the mobility of the tendon so we get in there I sometimes will put a traction suture in there. I do two lateral portals I view from a direct lateral and make an anterolateral porting you see we have to do some releases here to get that tendon over and This is we start with our bursal side releases in this case and sometimes these traumatic tears that tendon can actually with all that vascularity actually adhere to the underneath surface of the chromium and you see this big sheet of tissue and so you have to basically forms like Almost a pseudo tendon laterally that's not attached to the greater tuberosity So you really need to release that and sometimes it's fine that it's tough to find that tendon edge So we'll kind of start releasing till you get back to thicker tissue Release it off the acromion and then we'll look at it from laterally now We've got the tendon released on its bursal side. So it really just adheres to the underneath surface of the acromion So then we do our Bursal side releases first we work anterior here. It's important to get good visualization as well for your passage of sutures You want to release back to you kind of see the coracoid process? Anteriorly so you can do an anterior slide there if you need to and then we'll start releasing posteriorly here This is important to get a good release posteriorly obviously for my get the tendon over But also when you start passing sutures posteriorly here You want all that burst out of there because you can lose your as the shoulder starts filling up with fluid you can lose Your you know sutures back there. Then we do our articular side of releases mobilize it from the articular surface again looking directly at it You can put a traction suture as you do this I'll hold the tendon over and I use a blunt instrument and just basically Pycrest that articular surface and really release it off the glenoid you want to go back until you feel the spinous or the spinal spinous process more posteriorly If you do more of a shaving you at you risk injuring the suprascapular nerve Then we burr down the bone here It's important to get a good bleeding bleeding response obviously and we don't burr too deep because you start getting into that That bone too deep and especially an osteoporotic bone and you lose fixation for your anchors. This is my anchor placement I do a direct lateral portal they can get all three anchors through that I put my anterior anchor just poster to the bicipital groove I usually use a double loaded anchor one sliding suture and one more static suture in there Depending on the bone quality we use all suture if it's good bone quality if not I'll use more of a swivel lock type anchor and we so we place our anchors in there and then we start passing the sutures and it's important when you pass your sutures to have a You under the standard tear pattern because those ones that are more posterior medial you want to bring over laterally or anterior So you want to make sure that you start passing anterior or posteriorly so you can work up anteriorly And it's also important as you see here. You want to get that That's that superior capsular layer This is another picture here. We're working anterior. So I like to hold the tendon over you go through that bursal layer there and Once you get through that bursal layer I like to lift up and then you can see that superior capsular layer that thick portion of the tendon here I'm coming through a little superficial so I back up my anchor you can or by suture lasso You can also take another instrument kind of pull up that articulate or that superior capsule area where you want to make sure you feel A nice pop that lets you know that you're in the good portion of the tendon So as we reduce our tendon, we're gonna tie our sutures and on the right here I like to pull tension on the sutures and put them through a cannula and then you want to push that cannula Inferior and that gets you and you can see up in the upper screen there that reduces a tendon nicely if you just pull directly Lateral that tendons not going to you know, lay down where it's supposed to and then this is what we see Arthroscopically so you got pulling tension on sutures and then we take that cannula and we're gonna bring it inferior and that just reduces that tendon Nicely and then you can do your repair here medial and I like to tie these three medial sutures just to set the tendon So you're not relying on your reduction with your with your lateral row trans oscillates equivalent So here we're gonna put our anchors in I like to put our answer your anchor If you having a tear that's reduced post your medial you want to put your answer anchor in first because that's gonna pull that tendon Anteriorly, I like to come just posterior to the bicep. It'll groove there There's usually a little vessel there that lets you know You're in that area. You can also probe where the biceps is and I do this with external rotation So it gives you plenty of humoral head Anteriorly that you're not gonna be going into the joints. So we place our anchor make sure we like our tension And I do this for the anterior lateral portal here Then we're switch portals and go poster We go internal rotation put our poster anchor and you want to make sure you have a nice space between those anchors So they don't converge and it also provides for a nice better suture bridge type it's more Compression of the of the tendon there tap in her anchor. I use more self self punching anchors now and we're gonna tension our sutures and And After we do that, we're gonna look at our repair and make sure we like it kind of quick It's a quick peek go back down cut the sutures and then we're gonna Look and you want to make sure that tendon there's not a lot of dog ears I'm you're gonna have may have some dog ears But if you have a lot of dog ears that you probably didn't reduce it correctly and you're gonna have too much tension on that Repair. So the question is how did these more complex tears do versus the traditional crescent type tears? And actually they do pretty well in this study looking at one-year outcomes in term And so the reason they probably do well is that those if you repair them Even though they're more complex tears you recognize that tear pattern and you repair them appropriately. You're not going to get a Prepare under much tension and so you can get a good outcome and similarly looking at you type tears versus more traditional Crescent type tears they do just as well And again, I think it's important that you recognize the tear pattern that's going to be your key to getting a good result So, thank you very much Next we'll invite Catherine Burns to the stage She's going to help us to understand some tips and tricks for managing the massive rotator cuff repair All right, good morning I'd like to thank the chairs and a OSSM for inviting me to speak. I'm going to talk about Massive cuff tears my disclosures are available on the website So what are our options 2024 we've got a massive tear We just saw a beautiful technique for repairing large tears But we're gonna say this tear is not repairable you get in the situation where it's not repairable So I'm gonna talk today about repair plus a partial repair plus So when we think about the options of what we have in 2024 We actually have a lot of options for the massive tear, but today I don't want to talk about Reverse shoulder replacement anything where you're gonna give up on fixing the cuff at all So we're not going to do tendon transfer in this talk balloon I'm not going to talk about the bar technique, but we still have a lot of options available for how we're gonna address this problem The first thing of course is patient selection if you want a good result You're gonna have to pick the right patient for this partial repair plus type of situation So we look at the history the age the activity level of physiologic age comorbidities So obviously for patients physical exam is important We kind of touched on this if they've got pseudoparalysis for me They're likely going to be better served by reverse a true pseudoparalysis. And if they have external rotation lag, I'll think more about tendon transfer What am I looking for on x-ray? I want these patients to have no or minimal arthritis a chromohumeral interval of at least three millimeters or more So Hamada stage one to two two and a half is appropriate to think about this type of procedure When we look at the MRI these patients I expect them to have large to massive tears kind of a sign that I anticipate I may not be able to get a full Repair atrophy and retraction is okay I want them to have an intact or repairable subscapularis and intact articular cartilage on MRI minimal arthritis on MRI So once we have this patient, what can we do with them? Well again a couple things one thing you can think about is this cable reconstruction? So cable reconstruction was described by Chris Adams and it basically focuses on the suspension bridge technique Basically, you acknowledge that you're not going to repair the center of the cuff But by anchoring the cuff anterolean posteriorly you can restore some of the force cables and he anecdotally reports that they get good pain relief What about bridging repairs bridging repairs is a big umbrella? but it basically involves any techniques in which you're going to attach something at the medial aspect of the tendon and Then over to the lateral aspect of the tuberosity So you're going to bridge the gap between whatever you can get from the tendon to the tuberosity These types of techniques involve all kinds of options. You could consider autograph like fascia lata You can use biceps tendon and in fact There are a lot of different techniques described at this point for how to use the biceps tendon to bridge the repair You can use allograft including semi t allograft has been described or human dermal allograft We know right now that there's a lot of technology out there So there are a lot of graphs and patches available hybrid patches With collagen and PLLA and even all synthetic patches or internal braces. So so keep your eyes peeled There's going to be a lot of new options available. But when we look at these bridging repairs I'm going to touch on just a couple that I have familiarity with that have worked well So one option is partial repair with SCR. We heard a little bit about SCR earlier SCR by itself, we know that we can definitely have some issues or concerns But if there's any cuff tissue on top of it The way you do this technique is perform your SCR But then work to repair rotator cuff over the SCR the SCR is basically a bridge From the glenoid to the tuberosity with the cuff being repaired over it, whatever you can get Another option that I've been using a lot is a partial repair with a patch or a tuberoplasty type of technique So in this technique you take the graft it's a smaller graft You're going to cover the tuberosity and then once the tuberosity is covered You'll repair the rotator cuff over around next to whatever you can get Adjacent but the patch still covers the tuberosity. So this is a bridging technique or a tuberoplasty plus So what's the literature say about this? Well, there was a recent randomized trial looking at SCR versus patch augmentation and they found in these patients They had similar healing rates, but the patch augmentation did have shorter surgical time and was technically easier So am I a lazy surgeon? Is it shorter and faster and easier for the win? Yes, absolutely. It's been my experience. So This is a patient that came in about 10 years out from previous cuff repair The MRI wasn't very helpful because of the metal suture anchors It might have even been 15 years out But what we encountered here was a rotator cuff tear that was not fully repairable and you can see Tuberoplasty plus the graft is on the tuberosity. The tissue is repaired and it covers that Tuberosity, this is that same patient at four weeks out. So they are happy patients. They start to feel better right away Do I think his cuff was healed at four weeks? Of course not but these patients are happy and they're feeling better after this technique What about reconstruction with the biceps well again a lot of different options or techniques We know that the biceps is a local source of graft and low-cost it adds structure and biology and thanks to the work of JT We know that there are viable cells there even after manipulation. So this can really be a great option There are a lot of different options out there for how to use it One recent paper in the literature looked at what they called a bio SCR So the downside is there's a lot of different language about how to use the bicep But this bio SCR technique average age 67 They pulled the biceps out of the groove Did not to notimize it but used it to incorporate into the repair and they got good clinical results for these patients Another option you'll see here. It's an anterior cable reconstruction. So basically moving the biceps out of the groove This is a great option for those L-shaped tears, which we just heard about where maybe the tissue is kind of lacking anteriorly so this has been described and What you'll see in reality what it looks like when I do it is I'll move the biceps out of the groove secure it with a suture anchor there and then repair the cuff and What you'll see is right there. That's the biceps and then as I rotate Internally, you can see the cuff repair, but the biceps adds tissue anteriorly where I need it most in that particular pattern What about revisions? So we know that cuff tears they don't heal they fail If you're going back in a second time Is it the definition of insanity in? 2024 to go back in and try to repair the cuff again or do a repair plus technique This is video of a 70 year old pickleball player who wanted to avoid metal So I don't think it is the definition of insanity. I think that we have All kinds of options now for these situations So here I'm putting in some calcium phosphate to fill some of the bone defect That's there. And then this patient got the tuberoplasty plus humoral demoral allograft and then a cuff repair and Then this is the patient at three months out and she wants to go back to pickleball I'm gonna let her go back to pickleball at three months. So What are the takeaways in? 2024 well, first of all save the biceps use the biceps I've become a lot more thoughtful about doing tenotomy or tenodesis in my primary cuff repairs We know it adds biology bridge the gap cover the tuberosity It's a source of pain and that really may be a big part of why these patients are so unhappy in your office and then repair What's there? So give them a chance it may not heal but go ahead and repair that rotator cuff as much as you can over Thank you You Great next we'll have Eric Wagner. He's going to talk to us about techniques for Latissimus, excuse me trapezial transfer at the end of this if we can just have the panel come up to save time That'll be great as we have a limited time frame for the panel discussion Great. Thank you very much for this opportunity So I'm gonna talk to you a little bit about the low trap focusing on some technical highlights Happy to talk about some indications more after this Disclosure is not relevant to this presentation But I should disclose that when I'm making the decision to do a arthroscope assisted lower trapezius transfer I do make this decision preoperatively based off of variety of parameters of what defines an irreparable cuff There's many different factors and we can have a whole long Separate panel just on this alone But I do think things like the Rohy classification show that when you have a retracted tear you have fat infiltration You have a very poor chance of healing and thus I make my decision preoperatively going into this procedure So I'm gonna skip over some of our data and investigations on this and go to Sort of how I shorten my learning curve Maybe I can help you to shorten your learning curve with this procedure for me is about 14 cases This is from a surgical time standpoint Not necessarily an outcome standpoint, but basically you do the harvest as I'll show you in a second You harvest the trapezius off of the medial angle of the scapula You then transfer an Achilles allograft the largest you can get into the greater tuberosity I like to preload anchors into two set cannulas makes it a little bit easier once you do it arthroscopically Then I ultimately use four anchors to really compress down the graft Then you bring the arm an extra rotation and you anchor the graft into place A couple other technical tips when you're anchoring this I try to replicate the upper impersonatus So I'm placing it anteriorly on the greater tuberosity the first two anchors I also like to preload as I mentioned the cannulas makes it a little bit easier So you preload the two cannulas with anchors makes it a little bit easier to to bury these arthroscopically And then I'll show you you can also add in a biceps SDR as we heard and I'll show you that in this video That's that's to follow. So here's the incision So the incision is just basically a finger breath below the medial angle. It's you do not have to use a large incision Although initially maybe when you're starting out, it's not a bad idea I would advise excising out the fat overlying the lower trapezius in the south We have lots of people like biscuits lots of back fat once you identify the the angle of the The lower trapezius you can follow it up to the it's insertion on the spine and then at this point I'm just basically teasing it off of the medial spinal scapula teasing off the middle trapezius above it And you can see the nice muscle you can see the nice tendon on the back side Get pretty good excursion Tracy trying to replicate the excursion of the impersonatus. I do like to place this crack out stitch. This is a Stitch that allows us to do a pulver taff weave later on also allows me to sort of mobilize this this lower trapezius But you can see you can get pretty nice Excursion pretty nice looking tendon pretty standard arthroscopic portals. Nothing fancy here This is the the biceps SCR that I'm going to show you as part of this And we can talk about indications for that as well But it's more of I guess an anterior cable rather than a true SCR So I anchor or I place one Suture into the biceps just at that particular margin wrap it around a couple times and then bring it back through to create kind of Create a nice robust construct to the to the to the biceps. I then we'll just do a standard biceps Tendencies, so this is this is below the groove And and you can sort of pick your pick and choose how you want to do this T and E's as I tend to do an onlay one And here you can see I've sort of tagged it I'm gonna cut it in the middle and then I'm gonna place it in an onlay anchor But that's basically your choice on how you want to do this this T and E's this is placing the anchor Below the groove and getting the biceps out of the way, but now you still have the upper part for the actual SCR I do do a partial rotator cuff repair in every single one of these I strongly believe that you need to repair what you can in addition to augmenting it with the transfer I don't think doing a transfer alone, even if you have very advanced stages of fat infiltration makes sense So for this case, I'm using a knotless anchor I'm doing an inverted horizontal message that you can see them I'm Placing this and we'll anchor it down to the anchor and then I have these two other sort of ripstop type stitches That I will put into one of the graft anchors to help Help them help with it with healing of that emphysinitis So now I'm just marking out where I'm gonna put my four different anchors I put these cannulas in before transferring the graft and then I use a long hip arthroscopic grasper as you can see here Well, that's gonna allow me to bring the graft into the joint. So this is my Achilles allograft It's been prepared with multiple crack out stitches and then I'm transferring it into the joint as you can see here and then I'm Pre-loading these into the two cannulas and then putting anchors on those stitches I think that's really important because the graft is really thick It makes it hard to see if you preload these it makes it a little bit easier to see this first anchor has the bicep stitch as well as the interior and medial stitch from the Graft I'm anchoring that in place at the sort of anterior margin of the of the greater tuberosity That's your that's your second anchor And then I preload two other sutures just simple sutures about two centimeters back on the graft and I'll anchor these as well in place Creating a nice sort of box type compression down the graft this last stitch is your is your medial stitch that has the partial emphysinitis stitch on it as well as The actual graft itself and you can see there's your Achilles allograft. There's your anterior cable of the biceps SCR And you can see sort of how you have a nice compression Hopefully and a nice dynamic restoration once you finish this transfer. So now you're gonna move to the back. I bring the arm in abduction and external rotation, maximally externally rotate this. And then I like to do a pull over taff weave. So I split the Achilles graft and I bring one end through and tighten it as tight as possible. So I'm going very lateral on the graft, very medial on the actual lower trapezius tendon, and really trying to tighten this as much as possible. You really can't make this too tight. So this first stitch or two are really important to get it really nice and tight, really nice and tensioned. And then sort of, I'll usually place about four to six stitches for each limb of the graft to really secure this nicely in place. I have not had any failures of the graft to the muscle. I think it's partly because we secured with so many different stitches. So then I bring the other end, kind of wrap it over the top and secure it in place. I think once again, the one of technical pros is really you cannot make this too tight. You can see there with some internal external rotation, you see the graft moving, see how tight it is. I can barely get my finger underneath the bottom of it. So some final thoughts. This just shows a couple patients, a 56-year-old weekend warrior and a 62-year-old farmer, both pretty limited in their function. You can see the retraction of the cuff, the fatty infiltration, but the preserved teres minors in both. And in this case, you can see the gentleman was able to get back to basically normal scapular humoral rhythm. Babies, you get back to a normal overall function with very little limitations. And then you can see in the farmer, she was able also to restore scapular humoral rhythm, maintained it at four years post-op. It was relatively easy for her to actually retrain this transfer. So to kind of emphasize, Haley did a beautiful job presenting the study comparing SCR to lower trap. But if you look at fatty infiltration and those that have advanced fatty infiltration, the emphysema in particular, the lower trap really mimicked those that did not have fatty infiltration for the SCR. But those that had fatty infiltration, the SCR really did not do well, at least in our series. Happy to just sort of talk more about this, but this kind of feeds to our algorithm. You have good tendon muscle, you do a rotator cuff repairs, was beautifully demonstrated. If you have a tendon deficiency, repair it, augment it with an SCR, maybe a structural graft. But if you have muscle deficiency, you're playing muscle with muscle, and we believe at least in doing an arthroscopic lower trap transfer. So thank you very much for your time, and please reach out if you have any questions. Thank you. All right, we're going to move on to the panel, talk about some revision situations. If I can ask Gus and JT as our moderators and then the remainder of the panel, which I think we have here, we'll get started. All right, we got the famous J.T. Tokish up here. We only have about 10 minutes, right guys? Fifteen. Fifteen? Perfect. So one of the things we wanted to go with was just to introduce, so failed arthroscopic rotator cuff repair comes in. We don't want to necessarily get into all the different reasons of this particular case, but to really go down the panel and find out kind of what their indications were. These were some of the things, we're going to go back to this slide, but I wanted to give this little J.T. Tokish slide up there, which you saw, because he was the one that really started about looking at the indications. So let's just go down the panel, and I can't see who's down at the end there. Jed? Jed. All right, Jed, let's go. Failed rotator cuff repair comes into your office. What are your first things that you're really trying to look at to try to define what you're going to do? Well, the first things for me are what is the patient's issue? Is it a pain issue, but they have good function? I might approach that patient very differently than somebody that has poor function. So for me, that's probably the first decision point. Buddy? Anything to add to that? Same. I want to know what they want to do. I mean, why are you here? What can you not do that you want to do? And then that determines what options I'm going to present them. All right, you guys are really not biting here very well here. So all right, Eric, anything to add besides knowing what the patient wants? They're in your office, they're in pain, they can't play pickleball or whatever. Yeah, I mean, I think you want to understand, in addition to understanding what their actual goals are, you want to understand potentially why it failed, what are, if you can understand why it fails, then what are ways, if you're going to treat it, what are your true options to make up for that so you're not making the same mistake twice, or at least not repeating the same mistake twice, and then sort of present these options. I think it's very patient-specific, but I also think it's pathologic-specific on a lot of these debates and a lot of these questions we have about what to do with these massacres. So how it failed is important to you? Yeah, so how it failed. So why did it fail, and then what is it lacking at this point? So is it lacking muscles, is it lacking tendon, is it lacking biology, is osteoporosis a component? You know, what are the main things that you would have to make up for if you're going to do a surgery to reconstruct this, particularly if you're going to do something other than a reverse? So let me push you on that a little bit, for those of you that answered this. You said, I think Jed makes a critical point that says the patient that comes in to you with a big rotator cuff or failed rotator cuff repair, there's a patient that does this with it, says, my shoulder hurts, and there's a patient that does this, and I think that's what Jed's getting at, right? You guys are saying we got to do that. Okay, so my question to you is, is that your only driver? So for example, if you have a cuff that you deem repairable, technically, excellent surgeons here on the panel, and you got a patient who does this, and their complaint is pain, well, you just told us you're only going to address that function. So I could do that with a debridement, rehab, I could stick a balloon in, I could put chewing gum in there, all of it works, right? But my question to you is, is that enough for you because they have function, or will you still repair the cuff? Maybe somebody on the panel could address that. Yeah, and I think the last, sorry, I think the last question to finish that out, that thought out, JT, is what does the patient want, right? Because if they do this, and they say, I just want to sleep at night, and I want to be able to do my ADLs without pain, I've got good solutions for that. If they do this, and they say, I have no pain, but I want my strength back because I'm a weight lifter, I don't know that I have great solutions for that. Okay, so let's say you go take the biceps, the excellent point, you're treated today, but what about that patient that comes back to you a year later and now has lost that function? Do you worry that by not repairing the cuff, or anybody on the panel, do you worry that by not repairing the cuff, you're going to see a Goutelier II that might have been repairable in the revision setting, now is just Swiss cheese and never going to come back? So is it only the patient's wishes, or do you look at this and go, look, we need to fix your cuff, because if I don't, this is going to become truly irreparable down the road? Yeah, I think you want to look at that, but you also have to take into account the fact that you fixed it once, and it didn't work, right? So I don't know that we necessarily are going to change that natural history pattern versus addressing symptoms. So in the primary setting, yeah, I think I'm much more aggressive about fixing for that situation, particularly in lower-grade fatty infiltration or atrophy situations. In the revision situation, I think less about that, because I'm not sure that I'm going to get a structurally integral cuff-bone interface. And I don't know that a tendon transfer, these other things, SCRs, is going to prevent atrophy or infiltration anyway. Got it. Catherine, is it one and done for you, Catherine, with regard to, you know, this cuff comes back and it fails? Or will you always try to re-repair if you can? Take us through your thought process there. Yeah, you know, it's really been an evolution for me. I do a lot of arthroplasty, and I love reverse shoulder replacement. It can work really well in the right patient. But I think it's important to understand that at this point, we really do have a huge amount of options to select for our patients. And so that's why this nuanced discussion about what is their function, what is their goal, what is their complaint, what is their activity level, it is all going to play a role. And I know, JT, you've tried to make it into a neat algorithm. It doesn't always fit into a neat algorithm. But what I have found has been the significant player, when I discuss this with patients and do shared decision making, which is a for real thing with this, is their tolerance for risk. Because reverse shoulder arthroplasty, in many ways, can be a one and done. And I have some patients for whom that tolerance for risk is, that's what I want. And for other patients, they really want to avoid arthroplasty. So that can influence the discussion, as well as the patient's predilection for risk. So for the panel, just to show of hands, how many of you, in the setting of a cuff tear that's failed, that you believe technically is re-repairable with decent muscle, but who's 65, will go to the reverse as that primary choice? Potentially. I'm leaving my hand up, because I'm one of those that would do that. That's a good function. With no arthritis. And is your rehab different? So JT, you're telling me he has no arthritis, he has a failed cuff, and he can still raise his arm up, or it doesn't matter? So he has a functional impairment, and I can fix that cuff, and he's 65, I'm going to fix it again. You're going to fix that cuff. I mean, additional supplementation may do the thing, but I will repair his cuff. I mean, I'm going to get 20, 30 years out of it. Are there factors that go into that for you, buddy? For example, let's say this guy's ROHE score is 8. So he's going to predictably, or in most people's hands, predictably have a failure. So you're taking this patient through a cuff that you will technically repair, I give you that, and you're going to stick him in a sling, and it's a seven month recovery, or you can do a reverse, and that cat's doing this tomorrow. So if he comes in, and he has only pain as his main complaint, and doesn't care about function, and as Catherine did a great job with that, talk about all the different options, and he doesn't care about what kind of function, that kind of stuff, I'll do a reverse in a minute, because all he needs is pain relief, right? But if he says, I want to go back to tennis, and I'm right-handed, and it's my right shoulder, and I want to serve overhead, I'm going to fix him. I mean, hell, my patient's, the average ROHE score is nine. So it's not like I get a little- I mean, I consider the repair, but also augmentation, possibly, with a restore patch to give him a little bit more tendon. Eric? Yeah. My only concern with going to a reverse in somebody who has full function is that we do know that some of the dissatisfaction drivers in reverse is the higher preoperative functional status, and that potentially, you might lose some function, depending on how they do with reverse, and so while you'll take care of their pain, or hopefully improve on their pain, you're not necessarily going to make them super happy with some of their loss of function. So I think that's a difficult and important decision to come to with the patient, because man, you do a reverse in somebody that does this, and now they're doing this afterwards, they might not be so happy with you. Fair enough. And just before we get into the techniques, I'd love to ask the panel your thoughts. So Eric, you showed earlier today that one of your negative indicators was Goutelier 2, 3, or 4, and traditionally, we've sort of divided Goutelier into 3 and 4 versus 1 and 2. So does the panel have thoughts on that? Are we moving toward less and less tolerance for fatty infiltration, where the muscle's still there, but there's still a significant amount? Help us understand that. If I can get my attention, I'll open up. So in my mind, the fatty infiltration is the quality of the muscle, and how functional it actually can be. And while you might be able to get a successful repair, it's how successful that repair actually is. Interestingly enough, one of the papers talking about the teres minor fatty infiltration, they had fatty infiltration 1 and 2, and those showed worse outcomes with a repairable rotator cuff repair. So I think our understanding of fatty infiltration is evolving. For me, if you have deficiency, even grade 2, why not try to repair what you can and then augment it with a dynamic muscle, rather than trying to just depend on a muscle that's potentially compromised? Others? Jim? Yeah, I would add, when I look at the Goutelier stages, that's supraspinatus and infraspinatus, but I think you also have to pay attention to what their subscap looks like and what their teres looks like. If you've got a really healthy teres and a really healthy subscap, they may do very well functionally with bad Goutelier changes in the supra and infra. So those are things you have to keep in mind as well. Do you think teres minor hypertrophy is a good thing or a bad thing? I think it's a great thing. Now, the reason I ask is, in the arthroplasty literature, it's shown to be a very positive indicator, but there's been several studies in the rotator cuff literature that shows that it's not protective at all, and so that we might be over-cooking it. So you just had a paper, right? Yeah. A newspaper said that if you have teres minor hypertrophy, your rotator cuff's more likely to fail. Yes. Now, we also know that if you have teres minor atrophy, your rotator cuff's more likely to fail. That doesn't make any sense to me. It's going to fail. Yeah. And again, this cause and effect, you can't define relationships, right? So the hypertrophy probably happened because the cuff was failing. Yeah. Well, maybe let's move into a little bit of the approach here now. So let's talk about the little approach here. So Gus laid out this case very, very well, and maybe I'll just go down the line, and maybe I could ask each of the panel members very briefly, what's your approach to this patient with this failed cuff repair? Surgically. Surgically. Well, can I say something? Before we dive into the surgical and technical aspect, I think we have to look at the patient as a whole. Are there any metabolic factors? Do they have any comorbidities? Are they smokers? Is there a nutritional issue? Can we optimize that specifically with amino acid supplementation? Let me ask a question there. So that's a great point. So the patient's a smoker. Does that mean you're not touching her? We'll have a serious discussion and try to get her to stop for several months. You're going to wave your finger at her and then still fix her though? No, I won't. I mean, that's the question, right? If she's already failed once... We always say smoking, but then at the end of the day, you ain't stopping them smoking, so you're still going to operate on them, right? Not if they've failed once. If it was their primary, I'd have a soft discussion with them, but if they've already... Soft discussion. Yeah. The raffy velvet hand, I love that. The wave the finger, but still do it because they're in pain. But yeah, if they've already failed and that could be a major reason for it, I'm not going to do it again. Grant? So I think the number one thing is curb your enthusiasm or set expectations. I think you got to make sure that they're... It's a salvage situation. It's not going to be a perfect situation like their priority recovery, so you have to educate them on that. And I think in this situation, I would go in there with the idea of trying to repair what we can. If they got good function, we'll do a pair of whatever we can, possibly use the biceps already gone in this case. Yes. Biceps already gone, so we can't use a biceps SCR, but I'll often use that in a situation if it's still present. And then I think if you get in there, the subscap's intact, supra's not repairable. I mean, if you have some infraspinatus you can pull up, I would probably consider an SCR in that situation. Let me just ask one. I know we're running short on time. How many of you by a show of hands will use a biologic of some sort in this revision repair, assuming you're trying to repair? Buddy, which biologic? So right now, I would use the biceps below and a regenitin above the repair. So I'm going to do two things. I'm going to do biceps one way or another, just like Catherine showed, use it for an intercable, do my repair on top of it, and add a biologic on top. Something to improve vascularity. Buddy, you guys know this, but Buddy's published a paper on large and massive tears with that very patch and shown excellent healing results in the literature. You also raised your hand, Rafi. What biologic would you use? I think you have to do the mechanical strength augmentation. My preferred graft is a dermal allograft, but we also have to stimulate a biologic response. I think bone marrow aspirate also has some evidence in the literature. Nick has done a randomized trial and found the same results with herniacus. And those are primary repairs. This is revision. You have to approach it with both angles, mechanical strength and then also stimulating a biologic response. I mean, I don't use a lot of PRP, but the literature is actually pretty good for augmenting repairs. That's something I would... So how do you keep the PRP there? Because, you know, the literature does say that it helps it, but that's when we solidify it, stir it in a tube and everything else. And most of us go, do you have PRP? And we go, sure. And we stick it in the shoulder, right? Don't shake your head like you don't think I'm lying. All of you do this. And how does that stay there? So I never quite figured that out and understood it. So do you do anything special with your PRP? You know, truthfully, I don't do a whole lot of it, but the literature actually supports it. I think if you can probably get it somehow in that interface between the tendon and the bone before you maybe squirt it in, before you put your swivel locks or lateral row in, that may potentially trap it a little bit more. And then Nick, you've written the sort of definitive American paper on using bone marrow aspirate, but he said it was similar to Hernigo's data, but it kind of isn't, right? You guys had to look a little more carefully to define re-tears with Tsugayas and getting into the weeds a little bit. Now you probably know more about this than anybody in the room. Where do you stand currently on BMAC as an adjunct to rotator cuff repair? Yeah. So our data was different than Hernigo's in that we saw a better Tsugaya classification score, but not necessarily a difference in true re-tear rates, number one. And number two is, you know, the big thing that across the board when you look at these papers is we've got to, as surgeons, start to decouple this idea that clinical outcomes are dependent on tendon integrity or tendon appearance, right? Because all of the data, whether it's ours or others, you can't tell the difference in the vast majority of patients except for strength recovery with overhead function. And so I think that's where you have to look at, you know, what does the patient want? Are they looking for the best possible functional recovery with strength, which is younger patients, or are they just looking for pain recovery, which is generally your older patients? If they want strength recovery, then I think you need to do what we're talking about here, which is to get as much of the muscle tendon unit hooked up and bring in new muscle if you don't have muscle to work with. And that's where we use patches, we use BMAC, et cetera, to try to maximize the biologic environment. If it's an older patient, I think you do what's easiest and quickest recovery to get them pain relief, which to me doesn't equate to needing a structurally intact rotator cuff. That's great stuff. Katherine, you get the final question. You gave us an excellent talk on all of these augmented options. So if all of those options are on the table, what's your go-to and why? It's been a progression for me, but right now I really do like the tuberoplasty, assuming this patient's main complaint is pain, that they're wanting to avoid arthroplasty, because with that pre-op x-ray, depending on their age, I would certainly talk about reverse. But I like the tuberoplasty plus, repairing as much of the cuff as I can, and then covering the tuberosity as insurance for protection against painful contact. Eric, same kind of patient that she was talking about, would you do a lower trap transfer on that? This patient, in my mind, you have fatty infiltration. It depends on their goals and everything else that was brought up, but fatty infiltration or revision setting, you'd want to do everything you can to augment healing. But I would try to repair what I could, and I would do a lower trap over this, yes. That's excellent. All right. Great. That's it for this session. We could talk forever on this. Right? We're out of time. Thanks very much to our panel. That was awesome. I thought this was a rational opportunity. Thank you.

Raffy Mirzayan, MD

Nikhil N. Verma, MD

Haley M. McKissack, MD, BS

Stephen Marcaccio, MD

Grant L. Jones, MD

Katherine Burns, MD

Eric Wagner, MD, MS

Augustus Mazzocca, MD, MS

John Tokish, MD

John E. Kuhn, MD, MS

Felix H. Savoie, III, MD

rotator cuff tears

lower trapezius transfer

superior capsular reconstruction

teres minor atrophy

tension-free repairs

hybrid approach

arthroscopic techniques

revision strategies

biologics