This is a little bit about biceps autograph smash and how we do it, and just a little bit by way of introduction, ladies and gentlemen, we are not winning. You take a look at all the papers that have been published between 1990 and 2015, we still are looking at intact rates between 63 and 75%. So in spite of the fact that our industry partners and many innovative surgeons have come up with the most amazing mouse traps out there, we've got a biologic problem. And so we have to address this from a little bit of a different gig. So what can be done now to potentially enhance rotator cuff healing at risk? Well, there are xenograft options, right? There's porcine options, there's human dermal allograft options, there's bovine options, and all of these may have their place. But the best biology may be the body's own tenosyte. We know this from autograft versus allograft studies elsewhere that we have. We took a look at using skin graft meshing to do this. We were able to expand this tenotomized biceps into a patch, but we did see some decrease in viability, and it's a little bit difficult to handle in that regard. Fortunately, some of our friends in industry have come up with a much more innovative way to do this, and so this is the approach to the bicep smash technique that we'll show you today. We begin this with a super pectoral tenodesis. You can see the pectoralis major coming out right over the top there. I'm flicking it there, and there's the biceps cut and taken. So now we take the biceps, and you'd normally throw this away. We mark it at about 27 millimeters. That's what's used for the patch. We then put it into this compression device, which is the same thing we use to put a post on the back of a base plate for shoulder arthroplasty. We put it there for four minutes on max compression, and then we take it off, and when you get it out of that plate itself, it then gives you a beautiful and very contoured patch that matches the hole in the plate. We then can take that and prepare it any way we wish, but for the most part, we've been loading it onto this graft inserter. Makes it very easy. You can fold it like a paint roller, insert it into the shoulder just like this, and then unroll it, and it allows you a number of ways to do it. We'll show you a couple of different ways to attaching this to the medial side. We have worked with different devices that would include stapling with a bioabsorbable device, but we've now settled upon using a device that's all suture so that we leave nothing in the shoulder that can be reactive. You can see that it makes it very easy. You're right up on top of the cuff. You never have to travel away from that in any way, shape, or form. Once the cuff is attached medially, then we can remove the inserting device, and then we have these two pre-placed lateral luggage tag stitches placed in the lateral patch. These can be then just simply inserted either through anchors you've already placed for your lateral row for your cuff repair, or you can place a self-punching lateral row anchor into the greater tuberosity, and this completes the procedure completely. What I tell you is that it will add probably about 10 minutes to your case all in. It's a very short learning curve for us to be able to attach this to cuffs. I use it in partial thickness cuff. I use it in tendinopathy. I use it in patients with calcific tendinitis where you take out that calcium and it leaves a hole that all of us are uncomfortable with, and I'll use it to augment rotator cuff tears, especially those where Rohy scores are a little higher than we'd like them to be. It's been a reproducible graft in our hands so far, but of course we'll have to wait for clinical data as we come out. The MRI progression, we started out getting them at six weeks, but of course as you know cuff repairs look like a mess at six weeks, but you can still see the patch. By 12 weeks you can sometimes see the patch, but honestly at six months we can see that the patch is completely integrated. We have seen our Rohy scores and augmentation of this with hopefully data forthcoming showing that our retear rates have certainly gone down compared to what we would have expected from high Rohy or high risk patients as we go forward. So in conclusion, what we would say is that biceps autograft appears to be locally available. It's cost effective as an option for rotator cuff augmentation. Compression of the autograft can result in a reproducible and robust graft for insertion that does not compromise tenosyte viability as we discussed, but of course further study is warranted to determine if this augmentation technique results in higher healing rates and patient outcomes. Thanks again for your attention.

biceps autograph smash

enhanced rotator cuff healing

xenografts

allografts

body's own tenosyte