All right, so we're positioned lateral to cubitus. I think for cuff repairs, it doesn't make any difference. We've already done a release on the inside of the shoulder, and I think when you have superior migration, you want to release the inferior capsule so the head can move down. Moving the bursa, we clean it up. Now for these, we'll usually set up three portals. My lateral portal is about three centimeters down from the corner of the acromion, right in line with the front. So that lets you see if you have to do a distal clavicle, I think it gives us a better view. And then a posterior portal where we're going to insert all of our equipment, an anterior portal for suture passing if we need to. And then we'll make a superior portal right off the corner of the acromion right here, which will let us see. If we switch to the inside view now, and what Emilio and I decided to do is I was going to be a little quicker here, or try to be a little quicker, and so the cuff is already together. We started to make a split and then decided to leave it. So I don't know if you can see that right there, and we're going to cover that. So once we're in this part, the release that you want to finish here, and we're going to take this out for just a second, and put a trocar in here just to hold it, is in the front of the shoulder. So when we come back around to the front, we'll get our cautery to come in. The big thing is to clean out the lateral bursa so you can actually see what's going on, like you see here. And then we're going to come around to the front with the cautery, or with the shaver over here, prospastor shaver over here, and we'll show you where the front is because you want to really know for sure where your arch is. And so as we're here in the front of the shoulder, that's our shaver coming in from anteriorly, and we can clean out a little bit more here, and we can come around to the front. So this is more bursa here, you see all this kind of in the way there. We can move some of this stuff so we can see what's going on, as you see here, and that'll help clean all this out. And then you can actually come all the way to the front of the shoulder, and most of the time come down, find your conjoined tendon, which you see here, come over to the base of the coracoid, here, this is coracohumeral, there are two parts to it, and so either with a cautery or with your shaver, you do want to go ahead and release that. You can't really release this from inside, you want to release from the bursal area, so that's a pretty thick ligament, and it will restrict your motion, so if you're thinking you're trying to bring a head down, you're trying to do some different things, releasing this ligament off the base of the coracoid, like you see here, either with the shaver or with a cautery will make a big difference, both in bringing the head down and your motion and your flexibility, and so you really want to take that down completely and kind of expose your coracoid. You risk, of course, if you're here, if you drop down a little bit further, conjoined tendon, and come past it, you're going to get all the way, as you see here, you can come all the way down to where the axillary nerve is right there, so you don't actually want to shave that out. So once we finish that, then we can take this out, we can leave this cannula just kind of out of the way, sort of tucked in, so it pulls that back. We'll come back where we are here, make sure that we can see all the way laterally, if we're not sure, we'll bring the shaver back in from the back, and we'll pass that around here for just a second, and make sure you can really see laterally, because what you want to do now is not just see in the bursa, but make sure you know where your arch is, and one of the critical components when you're doing this is to keep the arch intact, so if you do a decompression, you don't want to do the spacer. Now when we get to that point, we'll talk a little bit about it, because what we're doing is an off-label use. So here we are with the top of the cuff, here's everything exposed, the muscle part, all the way around the lateral side of the tuberosity. We've already measured this, that this is going to be a small, I mean, excuse me, a medium on the spacer, but now we're here, so if we switch to outside, we'll show how we get set up to put the patch in. So that comes out, we'll put a switching stick in, and then you need a big cannula. In this case, we usually use an eight and a half, and it's nice to do it with the pickle, so that goes in from the outside here, and we'll bring this right in, hopefully we made a big enough cut here, and you can see the water spraying out the top. So then you want to make sure that this comes all the way in, like that, and then I'll hold the cannula, pull the rest of the stuff out, okay, so then we're in good shape here, and now we can see the cannula in place, so then we'll take our patch, we'll go back outside for a second, and then as we put this in, we bring it in just a little bit, and then it helps to kind of squeeze it a little bit, so that it'll open a little bit easier, and then the patch comes in the cannula, as you see here. Now we're going to unscrew the cannula now, not all the way to the hilt of the instrument, but give us about two centimeters between the white part of the cannula and the patch itself. This is a non-structural patch, it's porous, so it doesn't matter which angle you put it in, so here it is in here. Now we don't want to put it way over here in the muscle, we want to put it back laterally, and we want the front edge to line up right with the bicipital groove. So if we fire it now, it opens up, and you can see it lying on top of the cuff, hold that right there now, try not to move. So then we'll check and make sure, we've already made sure that this portal was going to go where we wanted it, and hopefully it will. Right there, like that, I'm going to back up a little bit, sorry. And then we're going to check, because we want to make sure that we can get this right where we need it to go, on top of the patch, and so then we'll make a little cut here, with a knife, and then we'll have a special cannula, look back outside, you can see that special cannula there, that's going to come in right on top, right almost into the patch. So now we need to staple the patch, and the key is you have to have one assistant holding the patch very still, because you don't want to lose your alignment, it will come right to the front, and it's a quick jab through, gentle pressure, and then your staple, as you see here, locks the patch down, and we're going to use, I use a minimum of four, I know people will say you don't need that many, and it helps hold it down, but I don't like to use the bone staples per se, because they're peak, so we like to kind of quad, get four of them in, and then assess where we are, and you just got to make sure that you get, keep your pressure down, so the staple deploys correctly, like that, and really holds it down pretty nicely, got one more, thanks, alright, so we're going to come, we have one there, so we want to make sure that this front part of it is really locked down well, just like that, whoops, alright, now twist and pull back gently, so you can see how this one right here was a little bit proud, so sometimes we'll hold that and take it out, and then as you look back, you go, okay, well, we didn't get any in the back corner over here, Amy, internally rotate a little bit, you can bring it, now it's pretty stable, and that puts it in place, and then we're in good shape there, alright, relax, buddy, can you, and that's it in place, so at this point now, because this was a big cuff with superior migration, now we want to go ahead and put the spacer in, it's an off-label use of that spacer, because our patch is solid, and so if we go back outside, you can see that this is a device, the little red knob on top, is where you're going to deploy it, but that faces towards the acromion, the technique will tell you to put it in lateral, I use it off-label only with a cuff repair, because I have to restore my forced couples, and so now that our patch is in place, we're going to take this cannula out, and then very carefully kind of slip this in, if it doesn't go in right away, we're going to stop, take the pickle, and just use the pickle by itself, and make sure that we can create a path, just like we did before, and see it come in, maybe, let's see, let's see the switching stick back for a second, because we want to make sure that we lay on top of the patch like this, and then we'll take that, yep, and then we'll put the pickle back over the switching stick, and make sure we have a space here, because we want this to lay a little bit more medial, I'll rotate this for a second, and just show you that it, where the arch is, is here, so that's a chromium, and we want to make sure that this is going to sit right behind the CA ligament, just to the medial side, and help hold the head down, and so that's our space in our path, so now we'll take this out, and work this in a little bit, hopefully, without disrupting the spacer, there we go, all right, so then I'm going to come over, that's it in place now, so it's sitting over the patch, we're going to have this rotated, and then, now go back outside for a second, we're going to break this red part off, we're going to pull this part back, without pushing this in, and then make sure we have this, you can go back inside, get your syringe, so now we're in the right space, so it's where you see here, push, there you, and you see it opening, we'll back up a little bit, and look how it holds the patch down, it pushes everything down, and then back up a little bit, about six cc's, got it, okay, and then go back outside again, now this red knob is very important, we're going to push this forward, not down, just forward, like you saw here, and then we're going to rotate this over, no, hold it, hold it still, and it clicks, and then all this comes out, go back inside, and then that's the spacer, you move the arm, make sure it's very stable, it's not going anywhere, and I think putting it from the back, lets you put it exactly where it needs to be for this, and that's what we wanted to show on this, because we wanted to give Emilio an extra five minutes, which is where we are when we switch to him, alright, Emilio?

surgical technique

cuff repairs

positioning

superior migration

spacer deployment