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

rotator cuff tears

surgical procedures

panel discussion

repair techniques

patient case

debated surgical options

subscapularis tears