Good evening, and welcome to the American Journal of Sports Medicine's webinar. Thank you for joining us. I'm Alexandra Campbell, AOSSM Manager of eLearning and Educational Products, and I will be the operator for the webinar today. Before we get started, I would like to take a moment to acquaint you with a few features. There are options for how you can listen to this webinar. If you have any technical difficulties hearing the audio properly, please try clicking the phone call option and calling in for the audio, or switching the speakers that are being utilized. At any time, you may adjust your audio settings using your computer volume. To send a question, click in the text box and type your question. When finished, click the send button. Questions you submit are seen by today's presenters and will be addressed throughout the presentation, so you can send in those questions as you watch, rather than at the end. There is CME available for this online activity. Here are the learning objectives, and here are the disclosures. At the conclusion of today's program, we ask that you complete a brief evaluation by going to education.sportsmed.org and logging in. Please take a moment to complete this if you wish to collect CME for this activity. At this time, I would like to introduce our moderator, Dr. Thomas Tadd Kremen. Dr. Kremen is a full-time faculty member at the University of California, Los Angeles, specializing in orthopedic sports medicine and shoulder surgery. He currently serves as a team physician for the UCLA Bruins Intercollegiate Athletics Teams, the chair of the USA Swimming Sports Medicine and Science Committee, and the assistant orthopedic surgeon for the Los Angeles Lakers. Dr. Kremen is a member of the AJSM Electronic Media Editorial Board, and will be moderating our webinar. And with that, I'll turn the microphone over. Thank you, Dr. Kremen. Thanks, Alexandra. I appreciate it. Just like to start off by thanking Donna Tilton from AJSM and Alexandra Campbell from AOSSM for all the work they did behind the scenes to make this happen. We really appreciate it. I'd like to say thanks to all of our speakers. We really have a all-star group of speakers tonight. I'm going to introduce them briefly in order. First, we have John Kelly. He's a professor of clinical orthopedic surgery at Penn Perelman School of Medicine and director of shoulder sports at the University of Pennsylvania. Then we're going to hear from Allison Toth, who's an associate professor and the executive vice chair of the Department of Orthopedic Surgery at Duke University Medical Center. And she's a team physician for Duke University, as well as North Carolina Central University. Then we're going to hear from JT Tokish. He's a professor of orthopedic surgery at the Mayo Clinic and director of orthopedic sports medicine fellowship there, as well as the medical director of the Arizona Coyotes. And then finishing it off will be Dr. Clara Azevedo, who's the head of the shoulder and elbow unit in the Department of Orthopedics and Traumatology at the Hospital of the Sam's. I'd like to say a special thank you to Dr. Azevedo, because it's now one in the morning in Portugal, and we really appreciate her participating. So with that, I'm going to hand it off to Dr. Kelly, who's going to speak with us about partial repair of these irreplicable cupboards. Thanks, Ted. I hope everyone can see my screen. These are my disclosures, all literary, pretty much. And we're talking about massive, quote, irreparable tears, but some of them really are repairable. And the principles of the talk are that partial repair can help many. We're going to talk about reestablishing forced couples, minimizing tension. Look for the subscap tear. I do inferior capsule releases, and I augment with graft as necessary. So who can benefit from a partial repair? So you have to have absence of anterosphere escape, no significant appreciable glenium arthritis, erosione necromia. And once you get past the Goutelier 4B, then I start getting a little nervous and start thinking of other options. So tonight's talk is going to focus on the cable and forced couples, which is really condensation of cuff tissue that is the business end of our cuff. This is all Steve Burkhart's work. You know, the business end of our cuff is really condensation of fibers at the lower border infraspinatus, upper border subscapularis. These are the true humor and depressor zones. And this is what we try to reestablish during a partial repair. So a forced couple is really opposing moments that provide rotation without translation. And it's necessary to provide that fulcrum to resist deltoid upper pull. And for that to happen, our lab has shown that you don't need to fix the supraspinatus. This is a rat model, basically showing that fixing the supra and infra is no better than fixing just the infra alone in terms of restoring gait in a rat. So if you're going to fix a massive cuff tear partial repair, you got to know about the subscapularis and the comet tissue, which is really, we did a study showing it's CHL and SGHL roughly in 50-50 quantities. And it's a very important player because it gives us something to sew to up top. And one of the key themes of my talk tonight is the myth of the crescent tear. In my experience, almost every tear has a mobile limb. And most of the time, they're L-shaped. A mobile limb is actually posterior, reverse L is mobile and posterior. And a paradigm shift for me was this paper by Mojizuki and Sagaia's group showing that the footprint of the supraspinatus laterally is very, very narrow. It's only about 1.3 millimeters. So if you have more than that exposed, guess what? You got infraspinatus and vomit. So for years, we've been told about crescent tears when really the reduction for a tear is oblique. And Buddy Sava taught me this many years ago. I didn't quite fully believe him, but it's true. It's worked out well for me in my tear reduction. Just like reduce a fracture, you got to reduce the cuff tear to do a partial repair. So is this a crescent tear? I don't think so. Look at that mobile limb. Bang. And that's what it looks like when it's reduced like a fracture. You see, folks, I'm not here to diss double row because I do it in acute tears, but the double row literature is really predicated on anatomic studies using acute tears. If you've got acute tear in the lab, naturally it's going to be stronger with a double row. However, that's not what happens in Mother Nature. Tears retract in line with the fibers. And as Burkhardt has shown us, usually there's an oblique component to reduction. This is what we see, the oblique component, usually infraspinatus, and Buddy Sava taught me usually about 45 degrees is a reduction. And this is what it looks like in vivo. So Steve Burkhardt wrote about this years ago. Margin convergence, I call it an oblique reduction, decreases strain in the cuff edge, tendon-to-tendon healing, which is much more reliable than tendon to bone. And Steve Burkhardt's hands, margin convergence without sutures, anchors, was no difference. He actually published this than just margin convergence alone. So the average anchor in Philadelphia is about $400, so you do the math. In fact, Steve Burkhardt goes on to say results of tears repaired by margin convergence were no different statistically from those repaired by tendon-to-bone repair only. So I have a friend of mine named Craig Morgan in Delaware. He just does side-to-side only. I'm not saying to do that. But we've lost the art of tear reduction for these partial repairs. The apex is where the mobile limb suture goes, and this is what we want to do. We want to actually create a tear reduction. And as I always say, if you have a dog here, don't put it in an anchor and just redo it. It's not reduced. So what are the pearls for some of these partial repairs that I use? I always release the CHL off the base of the coracoid. That's called an interval slide continuity. And I go up top and I release the rotator cuff off the acromion. I don't do interval slides except for that coracoid release. And it's something Buddy Sattler taught me. I do inferior caps releases if the head's high. It just helps my reduction. I'm saying Hail Marys here, hugging the glenoid to avoid the nerve. So this with an interval release helps reduce the head. I do believe in Steven Snyder's crimson duvet principle. I do burring of the head. I don't do microfracture, but I burr the tuberosity. And I do believe that helps the biology. Another pearl for these partial tears, I'm not a biceps killer. I'm self-professed. I sew the infraspinatus to the biceps if it's there. Steven Snyder taught me this 15 years ago, 20 years ago. This has served me well clinically. It's tissue. It's living tissue. And the final point is, you haven't seen the subscap, but it's seen you. The tears are very, very common. In my series of massive tears, over 90% of the subscap tear, the comma tissue affords not only the reduction parameters, but also when you go up top, you can have something to sew to. This is called Dr. Burkhardt's interval sliding continuity. So release it off the coracoid. Save the comma tissue. Go up top. Sew whatever's back to that comma tissue. And if you haven't used a 70-degree scope for a subscap, please use it. It makes your life a lot easier. And so when we advance the comma tissue by doing our subscapularis repair, what we get is something that looks like this. And your hole is going to be a lot smaller. So here's a subscapularis tear. Believe me, it is. And look at the hole we see here. And then once we fix this, look at the small hole. We advance the comma tissue. Then I go up top. I have something to sew to. It's much smaller than before. So I do my margin convergence in perspectives to the comma tissue. And you can get it. I usually finish up with tape. And I tension it. Notice the footprint is sacred. No anchors on the footprint, just on the side. And you have to enhance your repair with more number of sutures. I medialize like Snyder. I do matter simulation with burring of the tuberosity, ripstop sutures, and I leave the MC sutures long. And this is the graveyard of a double row which has no biology. There's nothing to heal to. So is this tear irreparable? I don't think so. Margin convergence, oblique reduction, patience, repair the tuberosity. And this is what it looks like. And you can have some many, many happy patients. And sometimes you get really lucky and get a full reduced. And augmentation, Alison's going to talk about this, does work. Alan Barber, honest guy. And you roughly have the instance of recurrence with a graft. And if I'm in trouble, if I don't feel like I'm happy with the reduction or the coverage, put a graft on. This is last week's case. Almost covered, poor tissue, throw a graft on. Tension it, throw a graft on. So does this work? Am I snake oiling you guys? Look at these four or five authors, constant scores from 71 to 80. It does work. And Buddy Sava, the best paper of all, I think. Partial was as good as full thickness repair. In our series, didn't quite do as full thickness repairs, full coverage, but our ASCS, our pen shoulder scores were 70, pretty darn good. So the bottom line, reduce the tear, fix subscap, advance that common tissue. The footprint is holy ground in my estimation. I've been releasing more inferior capsules because you gotta get the head down. You don't need a lot of anchors. And folks, as we saw from those series of five authors, partial repair can work. So thank you for your attention. All right, John, turn your camera on. I'm gonna ask you a quick question before I move on to Allison's talk. Sure. So you touched upon this in the talk. You know, whenever you're doing an SCR for one of these bridging grafts that Allison's gonna talk about, part of that involves partial repair, whether it's subscap or infraspinatus. So my question is, is the partial repair really doing all the work here and the graft is just going along for the ride? Or do you think there's something added to the graft? I don't know the answer per se, but I do know there's a guy named Bill Pennington who's done more SCRs than anybody in the world. And I've been hybridizing my technique lately, Ted. I've been taking my medial row and sutures and I put it under the infra and under the subscap. So it actually gives me a further level of humer head depression. So I think that whatever it takes to get the head down in your hands is gonna end up with a happy patient. So the answer is I don't know, but I do think that if it's gonna help with the reduction of the head, it's worth doing. Perfect. All right, next up is Allison Toth. Allison's gonna talk about bridging with Xenografts and she's gonna mention some of the work that she recently published in her article entitled Histologic Analysis of Porcine Dermal Augmentation in the Treatment of Rotator Cup Tears. So I'll hand this off to Allison. Okay, thank you, Ted. So with that, I really appreciate the invitation to present some of our work that appeared in AJSM this month and it's really nice to be part of this panel to talk about fixing some of these larger irreparable tears. So what we're talking about here is we've got tears that might be in the category of shoulder arthroplasty. We're not really talking about those with arthritis. JT's gonna talk about SCR, so we'll let him handle that. John just gave a nice talk about partial repair and we're gonna hear about SCRs as well from Clara. So I'm gonna talk more about bridging and specifically about grafts and the histology and some emerging information about how these grafts have some ability to remodel and I think that information's not well known, so I'd like to share that. So first, what I mean about bridging and I think John Kelly just showed this nicely, but this is a picture from one of my cases and this is a porcine dermal graft on the far right and basically you can see a large tear, really not very mobile here, but still I felt like the Italia grade was two and it was reasonable to take that on and so bridging with a graft involves, I'm gonna just go back for a moment here, but bridging involves, essentially it's, I will do a partial repair of that tendon as possible, but also cover that footprint and cover, use the graft as part of the construct attached to the tendon, so it's bridging and I'll show this in a moment in a diagram as well, but in the end, we've got really a nice graft covering and so when the patient is abducting the shoulder, flexing the shoulder, this really even acts as interposition as well and I think that that's helpful for pain and so forth. So let's take a look at a case, a recent case of mine and this is a patient who failed primary repair about three months post-op and came in and presented to me wondering now what are we gonna do and you've got this sort of tear where you worry there's still a tendon attached there laterally to the footprint and you've got one of these, one of these tears more medial and those can be a real challenge, but the patient still is fairly young and has very good muscle and so this is four months later, we got an MRI because she was a little worried about things and you can see a bridging repair where a graft has thickened, going in at like a three millimeter graft and that really looks like the tendon's in good continuity, you can see her muscle here, but that's kind of a typical appearance I'll see with bridging. So let's talk about grafts because I think some of the biology of this is interesting, I'll try to make it interesting anyway. Well, there are some synthetic grafts, there's less of those, but there are some and then there's a number of biologic polymers, but probably the most common are dermal grafts or different types of extracellular matrices and the reason that those grafts are probably something that are more popular and have, they have some ability to allow a regenerative process within that tissue when you have extracellular matrix and that's because it attracts the patient's own cells and that's the focus of our article in AJSM, so I'm gonna go over that in a moment, but there's a lot of different grafts and patches and purposely this slide has a lot of information and so we talk about the tissue grafts as opposed to some of the synthetics, there's just a number of grafts out there, two of them are no longer on the market up here in red, but I've kind of listed in blue, the porcine extracellular matrix graft versus bovine versus human at the bottom and you can see just a whole number of them and some are cross-linked and some aren't and we're gonna talk about why that might be important and then some are sterile and some are not and for patients that can be something that's important for you to know and for them to know about the sterilization process as well. So what does it mean to be regenerative versus reparative with a graft? So I'm gonna start on the right hand side part of the slide. So back in the day there was a graft called a restore patch and that was made of pig sub-intestinal mucosa and it still had DNA and some epitopes that on the porcine portion that humans would react to and so there were frequently inflammatory reactions but you get this sort of resorption scar kind of formation that can happen with that type of graft and then you can get encapsulation with any graft that's more foreign body. The body doesn't know how to integrate that so that's particularly cross-linked products will do that. The body will just encapsulate rather than grow into it or with it but most of the grafts on the market like the extracellular matrix graft, we know from animal models at least that they support regeneration and you can see here in a green monkey abdomen that there's a graft but the body's kind of integrating and gradually absorbing it and it's becoming part of the tissue and that's really what I'm gonna focus on with our work that we presented in AJSM here next. So I feel like it's important to kind of know your grafts if you're gonna use them. So back at the restore patch they didn't do well because they had retained DNA and epitopes that humans would react to and then synthetic grafts could often be encapsulated and so there's kind of been an evolution and now we're more at the restorative potentially where these extracellular matrix grafts have some ability to remodel and really the patient's tissue can grow into the graft and I think someday we'll have grafts that are less elastic and stronger and we're gonna be down on this end of the spectrum, hopefully not looking quite like this but at least really at the better end of an evolution of a stronger graft that's also biologic. And so I've done a number of cases with different grafts, started out with the graft jacket and kind of moved on through the porcine dermis when it was available to a number of cases and now on to some other grafts but certainly have some experience using those especially with bridging technique. And so here's the paper that we published here this month in AJSM, what the paper focused on is that we had patients that had the porcine dermal grafts and basically fortuitously we had biopsies from myself and three other surgeons at different medical centers at different times after implanting the porcine dermal graft in patients and some of the patients fell and got injured, other patients had various mishaps or something and were basically able to just get this opportunistic biopsy at different time points and so first on H&E stain, if we look at that dermal graft out of the box, it really doesn't have any cells in it which is purposeful and it's just again like porcine dermis and there's no cells, really no organized collagen in the same way of tendon because it's skin. A patient fell at 18 days and a dermal graft was retrieved and it really didn't look much different than coming out of the box and then at three months, there's a host cell infiltration, there's fibroblasts, there's some vascular channels starting and basically the collagen is reorganizing. By seven months, this is a patient that started swimming, 10 days post-op by the way, which was ill-advised with a graft and we start seeing some really more organized collagen, a lot less cellularity, more again, more collagen and vascular ingrowth and then at 10 months, we really see a much more mature looking tendon and this is a normal human rotator cuff tendon we got from a patient that had a four-quarter amputation for a tumor of the scapula so we could see a more normal rotator cuff and this is H&E stain but what's more compelling is the next slide in which we see with picoserious red stains so we can see the collagen better, a dermal graft looks very different out of a box because dermis or skin looks quite different but then we look at a normal rotator cuff tendon and then look at a human biopsy from a dermal graft that had been implanted for seven months and it really looks a whole lot different than the dermal graft out of the box, it's got really organized collagen and even more so at 10 and a half months, our last specimen, we really see organized collagen and this is taken from the dermal graft and making sure that's not on the edge next to normal tendon and so I think it's just really interesting to note how the body, there can be host cell infiltration, especially this collagen reorganization over time, it's truly a remodeling process appears to be happening and if you think this is just well, maybe we biopsied it from the wrong place, we're not the only ones who have observed some of these changes, Steve Snyder published actually first about this in 2009, he had a specimen retrieved, really was able to take a specimen from a graft jacket that had been implanted in a human for three months and you can see again the same sort of a lot of fibroblast cells in what was just a dermis and this really start to see some collagen. And then this is a connexograft or that dermal, the porcine dermal graft at three months in an African green monkey. And it's the same kind of thing, fibroblast, vascular ingrowth, and collagen being laid down. So, again, just interesting. We're not the only ones to observe some of those remodeling changes. And so using this in a bridging technique is just something that I started with more based on animal models at the time I started doing this in 2006 and 2007. And so really that grafts or bridging kind of had a bad rap, but there was a nice editorial showing that really most of the literature shows a very nice healing rate on both MRI, ultrasound, even up to 78% healing with these large tears using a bridging technique. And for bridging, I think to highlight John Kelly's discussion, I think it's very helpful and important to try to preserve the cable and do as much as you can for primary repair, bringing a partial repair, bringing the tendon back as well as you can to the footprint, but then using that graft in this bridging technique. I think bridging can certainly be a partial repair with the graft, helping to reduce that, add some extra strength to the repair. And this particular study in 2015 showed a large number of those intact, as long as there was a low grade of fatty infiltration, which I know Tad will highlight later. And so there is some biomechanical rationale with graft carrying up to 40% of the applied load across the repair site. So I think there's some helpful addition of the graft. And so I'm going to end up with just talking about some of the recent reviews of the literature about bridging and when grafts are used as simply an augment, like laying it directly over a thin tendon, there was a higher retear rate than when it's used as interposition. And I feel like that's because there's less stress on the tendon when you're using it like interposition rather than trying to tension it so much as an augment or overlay. And so we see this in several systematic reviews that augmentation versus bridging, that bridging has some very good results and very little pain post-op. And one of the things I'd like to highlight here is that comparing partial repair and bridging like with biceps or fasciolata, using a graft seems to improve the healing rate better than just partial repair. And if we look at some of the work in, and these are level four studies, but there's a high rate of repairs intact with using a bridging technique. And lastly, the latest study or latest systematic review of bridging compared to SCR, which I'll be interested in JT's discussion of that. But they're very similar graft healing SCR versus bridging, very similar complications, but bridging delivers slightly better results on some of the functional scores and pain and even some active external rotation. So I think bridging shouldn't be dismissed as something like there's only SCR or partial repair. I think the bridging technique really has some value and it's nice to be able to share some of this information with you. So I'll summarize by saying bridging reconstruction is promising therapy to address larger massive tears and we seem to see lower rotator cuff repair failure rates versus historical controls or just partial repairs. There's probably some load sharing by the grafts and finally some early histologic evidence that grafts might provide a scaffold for host integration, vascularization and collagen reorganization. So I think that information is important because as we can continue to develop grafts, I hope we really can balance that biology with strength of the grafts. And I think we're certainly someday going to have some great solutions to this problem. Thank you. If you can turn your camera on as well, I'll ask you a quick question before we move on to JT. Sure. Thanks, Ted. So first, as you know, the literature on really characterizing this biologic remodeling of these grafts is really pretty limited. So I think you touched upon pretty much every paper that's out there in your talk. So thanks for publishing it. We've gotten a lot of questions about rehab with these irreparable cuff tears. So maybe you could walk us through how you use this histologic data to guide your rehab recommendations in these patients. Well, that's a great question, Ted, because I think that my sense, as I know yours is with grafts, is that we do need to protect them longer. And so I think that there's no doubt that I keep the patient in a sling for eight weeks and any motion that I start within the first month, even those first two months must be all passive. And really, most of that done supine, Ted, to be very more cautious with being careful the patient's not loading the graft. I think the bigger picture is I really wouldn't start any upright strengthening of the patient, meaning flexion, abduction. I wouldn't start that for even about four months, which seems like a long time. But because I happen to know how the grafts remodeling, Ted, and all of the MRIs that I've had over time, the one you saw at four months where you saw the MRI of that how it's thickened and looks like it's a little bit better, like it's really beginning to heal. I really don't think the grafts tolerate active abduction flexion until we're getting to about four months. And I mean, again, upright. That doesn't mean we can't do some flexion and some of that work supine, but I'm really sort of careful about that. And then by six months, Ted, I think that I'm really letting the patient do more traditional like so weightlifting and push-ups and getting back to those things even at six months. But I really frown upon heavy overhead lifting until we get to nine months or a year. So I'd say I'm pretty conservative with that, which I think is really because I know at seven months and even 10 months, it's really remodeled quite nicely by then. I agree with you completely. These things definitely need a little more TLC and go much slower and you just kind of have to lay the crepe with these patients at a time. That's not going to be the rotator cuff repair that their neighbor had. It's a longer process for sure. So thank you. Thanks. With that, I'm going to move on to JT who's going to talk about superior capsule reconstruction. Excellent. Good evening, everybody. And thank you so much for letting me be a part of this, Ted. It's an honor to be on with you guys. It's a really fascinating topic and I think there's a lot of different ways to go at this. And tonight my task is to talk about the superior capsule reconstruction. I've been doing this since 2012 and I've experienced the good, the bad, and the ugly with this. And so hopefully maybe share some of the lessons that we've learned with this. My disclosures are available in the course book and the AOS. You know that the massive irreparable cuff tear remains very controversial because there's a lack of consensus on how to approach this condition. And we've got a lot to learn in this area. And in truth, our literature is actually quite terrible because we haven't done a very good job of separating the painful cuff from the dysfunctional cuff. So that's the first thing I would like to point out here. It's really about indications. This is a 65-year-old rancher who has bilateral massive cuff tears. And you can see that depending on which side you're looking at, this becomes a much, much more difficult problem. So if you look at this left side that he's using here, he's got great muscle and bad tendon. So guttale is zero, not much arthritis, et cetera. If you take a look at his right side, you see he's got arthritis, high riding head, hematic changes, grade four guttale changes. So on this right side, somebody doing an SCR and that someone was me at one point, that's destined to fail. But on the left side, this guy with an SCR is a potential home run. So if we want to take a look at maybe a treatment algorithm, I get this question a lot. If you've got somebody that's over the age of 65 and they've got DJD, please don't fool around with this. Just put in a reverse. These guys do great and it's an excellent outcome for that. The real problem though is what about the younger patient, right? So if you've got the younger patient with good motion and strength, so if you've got somebody who's got great motion, great strength, and they just have pain, well then you've got a lot of options. You could do a biceps, cut it. That works well. And Walsh have both shown doubling of constant scores. You can use the new balloon spacers. You can do rehab, Ofer Levy, some of the best data in the literature looking at that. So if you have a functional cuff, it is not the same as somebody who has pseudoparalysis. But if you have poor motion and pseudoparalysis, then the algorithm is this. If there's good muscle, I always say where there's muscle, there's hope, then this is one great opportunity for an SCR. If you've got bad muscle, then I think this is the indication for doing tendon transfers, lower trap transfer, and likelihood. And I think this is an algorithm that has been maybe a decade now almost in the making for me, and it serves me well now. And it has really decreased the failure rate in these cases for me. The second lesson I might say is to learn from our failures. So we published the first large North American series with Dr. Burkhardt and Pat Denard and the BRASS group. And we took a look, and these were the lessons that we learned. Pain relief was very good. We took them from six down to two. Our SES scores were good from 45 to 80, not perfect. And our satisfaction was just okay. And that's because we did the same thing. We made the same mistake. We didn't ferret out those patients who were looking for restoration of function versus those patients who just had pain. The other thing we learned was is that thin grafts don't work. If you do them in Hamada greater than three, so that acetabularization, those don't work either. And all our failures, at least structurally in that group, had a subscap tear and atrophy associated with it. So if you don't have a fixable subscap, the gig is up on this. I will say this. Pseudoparalysis, we get this question a lot, can be reversed if the muscle lives and you do it right. And with proper selection, I'd say that our failure rate in that group and personally has dropped down to well less than 15%. But I do a lot less of them. I think John's points about partial cuff repair are important. Extension grafts are important. And the way that I've migrated to do an SCR now incorporates all of those concepts. So the best technical point to reverse pseudoparalysis is a combination of the two. I believe that if the muscle lives, there's hope and you must incorporate the graft. So the way that we teach or the way that the SCRs often teach or taught is once you get the graft on, you do side to side repairs, front to back. And I think that's part of it, but I don't think that's at all the key. The key is getting a medial to lateral repair too. Because if you can preserve and repair the remnant, then you've got not only an SCR, but also an extension graft. So here's what I'm talking about. So this is an SCR that's already placed. I've pre-placed two mattresses in the graft beyond the glenoid fixation. And you can see this is the remnant infraspinatus that I'm pulling into view here. And so now I've got the native remnant cuff now tied down to the patch beyond the glenoid fixation. So therefore I have an SCR, but I also have an extension graft. And then this is the side to side normal stitch. When you're finished with this, whatever that patient has left, their grade two, grade three guttale changes, when they fire that muscle, it's going to transfer the tension across the graft and give you your best chance for restoration of motion. And this is what can happen with these patients. This is a 54-year-old woman who hadn't lifted her arm in over a year. She came in to me and then eight weeks came into the clinic and said, doc, doc, look at this. And I said, geez, don't do that. It's way too early, as Allison pointed out. But since you did it once, please do it one more time for the video. So she was lucky to get that on tape. So these are things that can be reversed. Is pseudoparalysis always reversed? I think anybody that tells you that is cherry picking from their indications. Lesson four is autograft may be just as good as allo. This is a biceps autograft SCR. Jeff Abrams actually turned me on to this. I was pretty skeptical at first, but you can see for smaller 15 to 20 millimeter gigs, I do a distal superpec biceps tenodesis, and then I bring the proximal limb. I don't detach it from the glenoid. And then you can bring it in and incorporate that. And my results with that have been very good. And it's an excellent option because it's cheap. You don't have the often $5,500 or more for the patch as well. And then finally, I think patch thickness matters. So one of the things that we've learned from Mihata's work is that an eight millimeter patch works better than a four millimeter patch. TFL seems to work better than human dermal allograft. But a lot of that is confounded by the thickness. So this got us to thinking, is there a way to get a spacer and a graft at the same time? And so there is actually. So most of us throw away half of the patch. So this is what we call the SCR plus. And we've taken the other half of the patch and we're resurfacing the acromion. So what we can do with this then is that this half of the dermal allograft, that's the SCR down below. And then if we take a look up, you see we've resurfaced the human dermal allograft. So not only on the acromion. So not only do we have the double thickness around seven to eight millimeters total in this, but we've also got a resurfacing concept that may help with pain relief. So the final lesson I'll tell you is prepare, prepare, prepare. This remains an operation that I believe can be a true game changer. But indications are critical and the case is technically demanding. This is something that please, if you're doing this, please go to the lab and learn from it. Go out and spend time with the John Kellys of the world or the Steve Burkharts of the world or the Terry Mahadas of the world who've really done a lot of those because there's a lot of lessons you can learn and tricks to make this a fairly straightforward. Evolution is necessary. The way that I do the case now is very different than the way that I did it back in 2012 when we first started. I incorporate the native remnant cuff. I think that's critical, turning it into an SCR plus an expansion graft. I add the dermal spacer. We do three anchors medially. So there's a lot of different technical aspects to this that we think have really helped this along. I think this can be a real game changing operation in many of those patients. And with that, thanks very much for your attention and good luck on your journey with this. Excellent. Thanks a lot, JT. Why don't you turn your camera on and I'll ask you a question as well. First, I think that algorithm was great. There's gonna be a lot of people taking screenshots of that algorithm and helping them guide their practice. That was one excellent point. I didn't include all the times I went off algorithm and screwed it all up because there's plenty of those. You can only show your best things, right? Right. So this kind of overlaps with some of the questions we're getting from our audience. And you touched upon this, but the dermal allografts we use in the States are obviously thinner and more compliant than the thicker, multi-layered autografts that people are using internationally. So how does that factor into your surgical technique as far as tensioning the graft as well as your post-operative rehab? Yeah, that's a great question. And I actually think that it matters a lot. So for example, Tiroo Mihata and our Japanese colleagues, they don't use allograft. And we in the U.S. often say it's because they don't have allograft available. But if you talk to Tiroo and many of our colleagues there, they don't use it because they don't think it works as well. I'll tell you why human dermal allograft is so popular in this country, because it's slick and it's easy. But the problem is if you put it on a machine, it stretches. It will not transfer force very well. So it's a bit of a siren song. So for me, I agree with you. And I do probably one third of the SCRs that I do are autograft. And it's a tensor fasciae latae from the hip. Or I'll use an allograft, but I'll use an allograft Achilles tendon. And the reason I do it is number one, you can double it and make it thick. And number two, the stiffness of the construct is really important. And what's really important about it is if we're depending on this to lift the arm, we have got to get something that's structural that just won't stretch out. So for me, the difference is if you've got somebody who's got motion like this with a lot of pain, then the human dermal is great. But if you've got somebody who's got this kind of motion and you're asking that tendon to actually be functional again, then that's an autograft or an allograft Achilles in my hands. And I do think that makes a difference. Excellent points. Yeah, you definitely have to be aware of all the different biomechanical properties of these different grafts. I also thought it was interesting that you sew the native cuff into the graft. I know Allison probably has some comments on that as well. It's interesting to see that people have evolved that way. The final question I have for you real quick is just how are you fixing that graft under the acromion? What are you using? Yeah, so I've done it a couple of different ways. Originally, I used a little ACL graft to drill through bone tunnels in there. That's a little technically challenging. So now what I do is I just put four corners or run an X-box stitch across the graft. So four corners. And then the medial limb go right through the AC joint and the lateral rim just go right around the edge of the acromion. And then you can tunnel it on top and just tie it over a bone bridge. It actually works quite well. It's a pretty simple technique. Excellent. I'll have to try that. With that, we're going to move on to... Sometimes in patients that can't do the rehab, we've also developed the SCR minus, where you don't add the patch at all. All you do is the allograft resurfacing on the undersurface of the acromion. And that was pretty good. But then it's even better. And sometimes we'll do, based upon some of the work by Rafi Mirzaian, who showed us that if it fails off the glenoid side, it works almost just as well as an intact SCR. So for those patients that can't do the rehab or can't wait for the rehab, you can do an SCR minus or just put the patch and just resurface the tuberosity of the humeral head and you may get good pain relief with those patients. Yeah, I know Mihata has been doing a graft for the capsule and then another graft for the cuff. So it's almost like a bio-balloon construct is what we're evolving to. All right. With that, we're going to move on to Dr. Azevedo, who's going to speak with us about autograft SCRs. So, hi, everybody. I hope you're seeing my screen. Thanks, Ted, for this kind invitation to talk about superior capsular reconstruction, the international experience with an autograft construct. The rationale of my presentation will be rather to talk about the rationale of using the autograft construct and why we still use it. So as we've all been talking about this today, in posterior superior irreparotator cuff tears, what happens is, as you see in this picture, the supraspinatus is completely retracted to the glenoid level. So it cannot transmit its stabilizing compressive downward force to the humerus. And so it does not resist the vertical deltoid pulling vector. When the patient attempts to elevate or abduct the shoulder, this disrupts the center of rotation of the glenoremoid joint. And what we're doing with the SCR is that we're using the superior capsular graft to transmit this compressive and downward force to the humerus. And this will resist the deltoid pulling vector, the vertical vector, and restore the vertical stability allowing for the preservation of the central rotation of the glenoremoid joint. But this is not enough. As you've heard in previous talks, you not only have to restore the vertical vectors, you have to restore the horizontal vectors. This is why it's so important to repair any tear of the subscapularis because you need it to push posteriorly to the glenoid. And you need the posterior inferior cuff also to compress and maintain the central rotation when the patient attempts to elevate the shoulder. And this is how you revert a pseudo-paralytical shoulder. Dr. Azevedo, I hate to interrupt you, but we're still looking at your first slide. Could you try to adjust your slides here? Yes, sorry about that. Sorry. Yeah, we missed the first diagram there. It sounds like you were talking about the diagram. You didn't see your... What are you watching? Right now we're seeing... My disclosures? I see a slide that's titled SCR, why do it, what is it for? You're on slide seven, Clara. But that's not what I'm looking at. Do you think it's a connection problem? You have more than one screen open, that often creates challenges. Clara, can you try to do your slideshow? Like click that button? Yes. So my slide now is SCR, why do it, what it is for, how is it done? Yeah, that's the slide we see. And now, do you see one with the ACR significantly improves shoulder stability? No. Clara, maybe you could try to close the presentation and then reopen it and then go to slideshow, that might help. Okay. Thanks, Jimmy. Thank you. I'll see you in there. But you're seeing my screen right now? No, right now we're seeing white. I'm going to try to give you the screen share again. I'm wondering if it only shared the notes version, one moment. And Clara, there's a little down arrow when she gives you the option to share it, click on the down arrow and it'll allow you if you have a slideshow that's up. That same thing happened to me. While we're troubleshooting here, John Kelly, let me ask you a question that came in from the audience. You can turn your camera on. Okay. Sir. Okay. Anything happen? The question is, does partial repair prevent the progression of superior head migration? That's been shown in a couple of studies. The answer is most of the time. Not every study supports that, but if you look at Steve Brokar's work, especially with repairing the subscapularis, it does seem to be a long-term solution. So I can't give any more data past five years, but many of the authors I've looked at, and the bottom line is the clinical scales, the clinical evaluations are longstanding. So there's one or two papers say that you do get, particularly when you repair the subscap in a very, very effective fashion. Not everyone's consensus with that, but I know Brokar has proven that. I just want to ask Alison, the bridging techniques are interesting, and JT, you mentioned the trapezius transfer. Peter Miller did it. It was kind of not a great estimate, but like about four years ago, he said that lower... What about now? Latissimus was not as good as SCR. So JT wants to comment on that. I know you mentioned that you do tendon transfers, but for my money, I think I'd much rather do a good SCR and, Alison, fix it, maybe get tension in the teres minor subscap like Pennington does. So I was just curious, the Peter Miller study saying that SCR wins over trapezius or latissimus transfer. What do you guys think of that? Yeah, I might argue it depends on if you've got muscle. So if you don't have any... If the muscle's dead, it doesn't matter what you put on it, it's not firing, so you need to do a transfer. I don't like a lat transfer. I don't think it works very well, but it certainly doesn't work well in my hands. But I think the lower trap transfer is a different story and can restore dynamics, especially for the posterior superior cuff. If the muscle's alive and you can get bad tendon, you can get it out to the edge of the head, you're in business. If the muscle's dead, the game's over. You got to figure out something else. You agree, Alison? Okay. Yeah. I like JT's thought about it. I think it's a great concept. And I think that, moreover, what he's doing about affixing the native cuff or tissue to a graft, even if that's the SCR, I think that's so important. I think that's something that I've always done as really almost part of that bridging idea. And I think he's right that... So really, I think that the audience should be thinking about that. Look at your lip muscle, look at your good talia grade, look at atrophy, and then you've got to consider... And I do think that you're really going to have to do something else. The grafts aren't going to work so well when the head's up high, your muscle's gone. I think you do need to do other things. So I really do like the algorithm that JT showed. Okay. All right. I think we've resolved our technical difficulties here, so let's transition over to Clara. Okay. So as I was saying, the most important thing so that SCR works is that you restore not only the vertical stability, but also the horizontal stability. And multiple studies have shown that ASCR significantly improves shoulder stability, and it works not only as a spacer against superior translation, but also as a stabilizer doing this job that I've just described. So the groundbreaking results that impressed us all and made us want to follow on this technique were the results published by Teresa Mihata in 2013 with 24 shoulders, with a minimum follow-up of two years and only 5% of graft tears. And they followed on this work with a minimum follow-up of five years with only 10% of graft tears. And in this technique, Teresa Mihata used a fascia lata autograft, which was fixed to the supraspinatus footprint with a trans osseous equivalent type of fixation. And this is very important. And if you look at systematic reviews comparing many treatment modalities for the treatment of irreparable rotator cuff tears with preserved galaneumocartilage, you see that when you use fascia lata autograft, SCR showed the largest mini improvements in the constant score, which is a score that has an objective assessment of the strength of the shoulder, compared even with muscle transverse partial repair, cervical misplacer, graft reconstruction, and deltoid flaps. We were really impressed with these results in Europe, and we want to follow up on this, but we were concerned, as in the rest of the world, with donor site morbidity of harvesting the autograft of the tensor fascia lata, which Teresa Mihata and co-workers harvest from the proximal tie, and they harvest the intramuscular septum down to the bone to make it thicker. And we were concerned not only about the cosmesis of this approach, which is open, but also with the potential damage to the tensor fascia lata and the hip abduction function. So we proposed a different technique, not only concerned with the cosmesis, doing only two centimetre incisions to harvest the fascia lata, but harvesting from the mid-tie to avoid damaging the tensor fascia lata proximally, and to avoid damaging the iliotibial band distal limb, which is an important anterolateral knee stabilising function. And we published some works in Kessler Journal and the OJSM about the donor site morbidity and showed that this really isn't significant for these patients who have really severe problems with their function in the shoulder, and we can even compare biomechanically these two types of grafts, because harvesting from the mid-tie, you have a thinner graft even if you fold it three times, than if you use the proximal fascia lata and the intermuscular septum, where you can achieve as much as 10 millimetre thick grafts. And we continued doing this procedure since 2015, because really you need an intact graft if you want to continue to preserve the vertical stability, and we were concerned with results that came out from multiple papers regarding the graft tear rate, either of human dermal allograft or porcine xenograft, and so we continued using the fascia lata, which seems to produce the most intact grafts at the longer-term follow-up. We had some patients we had to revive from other colleagues with porcine xenograft, and the literature shows that these grafts tend to fail earlier at follow-up, and the literature also is kind of inconsistent with the control with MRI of the graft survivorship. And also other alternatives as the fascia lata allograft that seem appealing have shown inferior results regarding graft tears with high graft tear rates at a lower follow-up than with autografts. And also I started talking about the question of the fixation in humeral footprint, and you see that to date you have more than 26 studies using a double transoxys equivalent type of fixation to fix the graft laterally, with very good results at the long-term, and only two studies rather than three, because this is the same study by Li and Min using autograft and using human dermal allograft, you have very high graft tear rates at the earlier follow-up, using only a single row type of fixation, so we shouldn't change this type of fixation, even though it's more expensive to use more anchors, of course, because you have better scores and higher external rotation in patients with intact grafts, and this is what you need. And as you listened from the previous talks, you know that if you want to produce good results you have to restore the horizontal force couple, so you need the subscapularis to work to reverse the paralysis, and the results of the studies have shown that ASCR can produce better results if you repair or if the subscapularis is intact. And so, of course, even when you have massive irreparable tears, you should try to check if it's irreparable, and as John Kelly just explained in the coma time, it's very important to reduce the subscapularis tear, and then you may be able to do a partial repair and avoid an SCR if you can achieve a total repair. And this image is to show that most of the patients who really have massive irreparable rotator cuff tears, frequently they don't have the long-headed biceps available, like in this case. This case was repairable, but as you saw, they didn't have the long-headed biceps available to use as an autograft. And this is what I wanted to discuss with you. In our short series of 76 patients, 29% of the patients did not have a long-headed biceps available to use as an autograft for the SCR, and if you use this technique to treat recurrent tears, this rate is even higher. We had 85% with no long-headed biceps available to use as an autograft. So the fascia latae is always available in your patients, and since we started, we've changed our technique to interpose the polypropylene mesh, like in the works by Colana et al., to try to improve even further our results regarding the graft tear rate. And we've been doing this, and this is not a cheap technique. Some argue that if you're using fascia latae because you want to save money, particularly in Europe, where we don't have the human duralumin allograft in most of the countries, the alternative is xenograft or allografts from cadavers, we have to use at least six anchors to fix this graft. So it's an expensive technique anyway, and if you repair the subscapularis, you need more anchors, and if you do it in this long-headed biceps, another anchor. But fascia latae is really easy to use, it's really flexible, as you can see here, in comparison with porcine xenografts, where it's really difficult to pierce the graft, to suture the graft ex vivo, you have to use special piercers here, you're using the same piercer you use to pass sutures in the rotator cuff, and it's really easy to slide this autograft inter-articularly, because it's really flexible, and so you see it's relatively elegant to slide this graft inside to do the SCR. So in conclusion, the main point of all of this is you have to restore the vertical and the horizontal force couples, you have always to repair the subscapularis tendon. If you cannot repair the subscapularis, you have to do a muscle transfer to mimic the subscapularis, otherwise the SCR won't work. You have to repair the remnants of the posterior inferior rotator cuff, and to have good results at a longer follow-up, you need a fascial auto-autograft, because it's shown it's going to have lower tearing rates. Thank you for your attention, and sorry for the technical mishaps. All right, Claire, why don't you turn your camera on, I'll ask you a question as well. Great talk. Go ahead. Yeah. Great talk. I used to think I would never, maybe three years ago, I thought I would never do an autographed fascial autograft, but after doing more and more of these LUTs by the knee, it just doesn't seem that different if you go more proximal in the thigh. The question I have for you is, how do you tension your SCR constructs, knowing that these grafts are sort of stiffer biomechanically, especially if you're putting in some mesh on top of that, what's your surgical technique for tensioning it? And I'm also curious about the rehab of these things in your practice. Actually, these grafts are not that stiff, unless you use the TFL and the intramuscular septum where you have really thick 10 millimetre grafts, and then you place lots of sutures like Mihata does. Our graft, even using the polypropylene, sorry, mesh, is not that thick anyway, but in our computational analysis, as I showed you, we analysed that to see what would be the ideal position of fixation of the graft, so that it would allow the SCR to perform more stable and with a lower graft tear rate risk. And we found that if we placed the shoulder while we fixed the graft at between five to 10 degrees of abduction, 70 degrees of flexion, this is how we position our patients, and with 10 degrees of internal rotation, the SCR would provide more stability and a lower graft tear rate, so that's what we've been doing regarding the tensioning of our grafts. Regarding rehabilitation, we're really conservative, like Alison said, we're concerned about failures, so we don't allow our patients to do resistant exercises for the first six months, but for the first three weeks they wear a sling, we avoid flexion exercises with the elbow for six weeks to protect the tenodesis of the long head of the biceps, because we always either tenotomise or tenodesis the long head of the biceps, so we have to protect it from the risk of Popeye deformities and other problems with the LHV, and then on, patients are allowed to perform forward flexion, but active, but not resistant, no resistant exercises for the first six months. So this is going to delay the rehab a little bit in terms of function, because they will recover their full strength after eight months, but it's worth it to lower the graft tear rate and for the long run results of the SCR. Excellent points. All right, we're running a little over, but I want to have everybody get on one last time for a little rapid fire, a couple more questions, and then we'll hand it off to Alexandra for some final details. All right, so we'll start off, I'm just going to go and order my screen here. So are you doing these cases arthroscopic or through a mini-open approach? Clara? All arthroscopic, a three-portal approach, a posterior portal, lateral portal, and anterior portal. Of course, the lateral portal has to be a little bit longer, eight millimetres on average, because of the graft, it's relatively thick to go inside and not to entangle it in the soft tissues. But it's arthroscopic. Alison, I know the answer for you, but I'll ask you for the rest of the audience. Yeah, well, it might surprise you, Ted, and I think you're familiar with this with me, but I think you have to do this partially arthroscopically. You can't really, I think you can't do grafts well. I think the, you know, placing glenoid anchors for the SCR and suturing medially, this so far, you know, retracted frequently, you need to do that arthroscopically. And so I think, you know, a fair amount of the case is arthroscopic. I think where I differ is the mini-open approach to the lateral aspect of tensioning the graft, because I can resect graft at that point, tension it anywhere that I want that. And I think if you do a mini-open approach well, you have great access by internally and externally rotate. I can sew that anterior-posterior as well, you know, and so I think it's just a really a combination of those two approaches is really effective. Dr. Kelly, how about you? Are you doing these partial repairs open or arthroscopic? I've been accused of having arthroscopy as a way of life, but the more severe the tear, the more medial retraction, the more better I can see it arthroscopically. So, but I do have such respect for Allison and, you know, I think going in trouble laterally, it's no harm, no foul, making a little incision. J.T.? Arthroscopic, although, you know, sometimes you get these with a big subscap tear too, and if you just come right off that lateral border and down into the RAFA, you can make that three-hour SCR turn into a 45-minute, much faster case. So I think open surgery, like in so many other areas of the shoulder, has gotten a little bit lost in terms of the art. The open surgery is very good, but I do mine arthroscopically. And final question, one thing I've noticed is that these patients, whether it's bridging or SCRs, tend to have less pain than your average rotator cuff. What's your experience? I'll start with John Kelly. Are they less pain with these partial repairs compared to your average cuff, or more pain? Are you tensioning it more? What's your experience? I just want to make one little comment, though. You know, J.T. and Allison, who are admittedly less smart than I am, talk about muscle, but I still think there's a principle of Pearl in the SCR as a biologic reverse. Regardless of muscle quality, I think it still serves as a depressor. So in my experience, I can't tell you whether there's less or more pain relief. You know, if I get them down and I have some clearance of the chromium, they feel better, but I cannot tell you whether it's less or more. Can't work as a reverse, a biologic reverse, because as soon as you abduct the arm, you've taken tension off. I'm telling you, J.T., as we say in South Philly, I'm telling you, I've helped a lot of people who've had no muscle, but not everybody. But I think I do it right, you've got to do it right, you've got to do it right. I think Pennington's right, I suture the front and the back, capisce, capisce? Allison, what's your, what's your opinion? Well, I think that John Kelly's funny, that's my opinion. My other opinion is that, yes, well, I think the graft also functions as interposition. The thicker the graft, probably the better there. I love what J.T. does with the acromion, because I really think that even though there may be, you know, not tension when you're abducting, you get that interposition effect. I actually bring the grafts more lateral, I bring them two centimeters down the side of the humerus for that reason, so when the patient abducts, they've still got the nice soft tissue interposition padding, you know, that between the tuberosity and the acromion. I think that's actually a lot of the pain relief, as was brought up earlier. And Claire, how about you with these autograft constructs? Less pain than the average rotator cuff, or the same? Yes, actually, what convinced me in the beginning was the difference in pain. The patients who underwent SCR complained of much less pain than patients who had massive repairs, I had to do lots of tension, lots of anchors. So this really impressed me, and I think this is because the SCR works as a stabilizer, and it protects the rest of the repair. It protects the subscapularis repair, it protects the posterior remnants repair, because it restores the center of rotation. This may be one of the reasons, not only the fact that you're not pulling all the tissue laterally, which causes pain, but also because it protects the healing of the structures and patients probably will have less pain because of this. But early on, it's really impressive, the difference of reduction in pain between SCR patients and rotator cuff tear repairs. Hey, Taq, one last thing, and then I'll shut up. I'm right now at San Diego Naval with some really smart people, including Jimmy Bailey, and they've taught me the value of the balloon. We didn't talk about that. The balloon can serve as an adjunct to whatever you're doing, just to lower the head and to help restore that force couple. So just final comments, and I promise I'll shut up. Sometimes I wish these people had more pain. It's going away, and until we get a permanent one, I'm not terribly convinced. Again, we have to separate out those with pain versus those without motion. If you do this and you hurt with a massive cuff tear, a balloon's going to work great. But if you've got this, that balloon might work for a little while, but as soon as it goes away, that balloon is over. I'm saying a balloon, and that's an adjunct to repair to help detention. So yeah. I wonder about that. Sometimes I wish these patients had more pain because you're trying to slow down their rehab, but they feel too good. With that, I think we're going to wrap things up here, be respectful of everyone's time. We're going to say thank you to all the panelists again. Thanks for sharing your thoughts and spending time with us, and we're going to hand this off to Alexandra for some final details. Thank you. Thanks for staying up all night. Nice to see you. It was great. Thanks. Dos notches. Thank you. Gracias. A big thank you to all of our panelists and presenters for their work on tonight's webinar, and thank you to all the attendees for your participation. If you're interested in CME or would like to view the recording of this webinar, please go to education.sportsmed.org, log in, click My Resources, and then click the course title. You can then complete the evaluation for CME or view the recording, which will be available by Friday. This information will also be emailed to you in 24 hours, so please don't worry about remembering at all. We thank you again for your participation, and have a great rest of your night. Thank you. Thank you. Thanks again, Ted. Great job. Good night. Thank you. Congratulations. Awesome.

webinar

massive irreparable cuff tears

Dr. Thomas Tad Crimin

techniques

partial repair

grafts

superior capsule reconstruction

autografts

surgical technique

patient outcomes