I think you guys have been relatively kind to one another. I've paid Brian's permission to go after him a little bit. So I got six minutes, six points on why to convince you guys to do your abductor repairs endoscopically. These are my disclosures. They're available on the Academy website. Now, this talk is not without its irony for me because after fellowship, I spent time with Brian at HSS to learn this as well as several other techniques. And Brian is exactly who you think he is. He's an absolutely brilliant teacher. He is a technically gifted surgeon. And he's a really, really great guy. So you guys are probably thinking I'm going to go easy on Brian, and I'm not. Because Brian, unfortunately, is wrong, and he's lost his way. So I'm here to show him that this is the way. And at least today, BK will not have it his way. So we'll start with portals. And I think the portals are important because when I started, I used Dr. Bird's portals and Dr. Kelly's portals. And what I found with it was it made the repairs rather cumbersome and took a lot of time. A 70-degree arthroscope is not needed for this. I tried to envision in my mind's eye what I could do to make this the most efficient repair possible. And I did what I knew, and that's to create basically a rotator cuff repair procedure. We all know how to do rotator cuffs. We've all been trained on this. And one of the big advantages that you can have is to actually plan these out under fluoro. And so if you imagine in your mind's eye that proximal anterior lateral portal, that's a 30-degree arthroscope giving you the optimal view, almost that 50-yard line stadium view, and then the dollop portal. That way, you can use antegrade suture passing to gently slide underneath that tendon and to be able to do this efficiently. Number two, the IT band. So this is a question that remains unanswered. And Robbie Westerman and I sought to try and answer this question. So with my portals, I split the IT band. I went through a phase where I would repair that IT band at the end, but what we found in our study when we reviewed the literature was that you would actually have better patient-reported outcome scores when it was all said and done at the time of final follow-up. And believe it or not, your re-tear rate was low. Now again, there's a paucity of literature out there, so we don't have enough data to say this definitively, but the IT band does indeed seem to matter, particularly with an endoscopic repair. What about tissue quality? Anybody who's endeavored to repair these, either endoscopic or open, has realized, as one of my old mentors used to say, this is akin to sewing snot to a moonbeam. A wonderful study out of Japan in 2019 in JBGS showing the thickness of the gluteus medius and minimus tendons. And if you look in the central portion of these tendons, there is a watershed area that's almost less than a millimeter in terms of its thickness. And again, this may have implications as for A, the tear pattern and where these tears arise from, but also in terms of our technical ability to repair these. Sure enough, this is borne out clinically. We can see three different examples of full thickness tears of the gluteus medius. And you can see how thin and attenuated that tissue is. And that's one of the reasons, I think, that some people have strayed away from doing this scopically and are doing it open, is the potential worry about tissue quality. So how do we address this? We published on this way back in 2018. That was about five years ago. And augmentation seems to be the way with these. This is unpublished data, but we're looking through our numbers and comparing these in a matched cohort. You can see on the left, that's an acellular dermal patch. In the center, we have a bioinductive patch. And then this is a newer patch that's a hybrid that's PLA as well as type one collagen. But when you think about these tears and you think about the tissue quality itself, augmentation, I'm more apt to do that in a gluteus medius or minimus tear than I am in any other tendon that I repair in the human body. So what about open versus scope? I can guarantee you that Brian is going to tell you guys that he is faster open than he is with a scope. So I just had my staff pull the last 50 that we did. Again, this has nothing to do with me. This has to do with the portals and the ease by which you can pass using the newer portals. 26.2 minutes was our average scope to skin for primary repair. If we add an augmentation and it didn't matter whether it was bioinductive patch, acellular dermis or a hybrid, that augmentation time was about 47 minutes from skin to skin. And the most important thing that I'll tell you is the morbidity. We forget that these studies all showed equivalent outcome between scope versus open, but the morbidity was higher. We have greater blood loss, greater risk of infection, pain postoperatively. These are all things to consider when you're thinking about going open versus scoping these. So I would ask everybody in the audience, if you have a rotator cuff repair today by a show of hands, who wants it fixed open? No one. Who wants it fixed arthroscopically? And we can go down the line with this. And essentially it is incumbent upon us. We're not open surgeons. We are arthroscopic surgeons. And we need to continue to push that limit and push that envelope. And again, the most important thing is the patient. If we can avoid morbidity, get equivalent outcomes and be able to provide a great repair and outcome for the patient, that's what we're incumbent to do. So in conclusion, all that we discussed matters. All of these things are reasons why you should consider doing this endoscopically versus open. We need to think about the future, where we're pushing the future, and being able to provide the best outcomes for our patients with the lowest level of morbidity. Thanks. That's my wife and my kids. That's part of my life. Thank you.

endoscopic repair

rotator cuff repair

augmentation techniques

tissue quality

arthroscopic surgery