I want to introduce to Dr. Tokic. I want to invite him to the next presentation. It's going to be about management strategies to address massive irreparable rotator cuff tear in active patients, current options, and algorithms in 2023. Thank you, Pablo. Congratulations on a great session to you and Allison. My disclosures are available in the course book and at theaos.org. And if you're like me, you struggle a little bit with the number of different approaches that are out there with massive irreparable cuff tears. And this patient of mine might demonstrate kind of what we all go through. This guy has a massive tear on both sides. And I've already injected him, so I've taken away his pain. So this is not pain-limiting. And on the right side of this guy, you can see he has arthritis, a high-riding head, massive guttale changes. And on the left side, he has good muscle. And I think you would agree with me that this is not the same animal from side to side. The problem is, if you look in the literature and you say, okay, how should I address the right shoulder or the left shoulder, you can get nine different techniques that are out there. We did a systematic review on this, and what we found is they all work. From rehab to SCR to RSA to RSA with tendon transfer to injection to balloons, everything. Well, clearly, that's not the case. And so we need to be a little bit more nuanced in the literature about how we approach the massive irreparable cuff tear. And so that's my task over the next few minutes to share with you in this. So in decision-making, I think there are some things that we can do in terms of an algorithmic-based approach in this regard, and so I'd like to take you through mine in the next hour and 45 minutes. In all seriousness, this actually comes down to about four decision points and questions, I think, that we've learned over the last 10 years working through this process and trying to follow and publish our data. The first question that you have to answer to yourself is, does this patient have significant DJD or not? If they have significant DJD, then I think we have to look at it, and that's similar to this guy on his right side. He's got Hamada grade 4 or 5. He's got terrible muscle. Please, just replace his shoulder. When we start talking about balloons and massive cuff tear repairs and all the technologies and dermal matrix, I sometimes think, please stop the madness, and I'm part of the problem here. But I think that we, you know, this is a wonderful operation, very reproducible in that patient with arthritis, and most of the failures that we had in SCR, et cetera, when we stretched the indications to try to do too much with it. But that's an easy one, and nobody wants to come listen to a talk about that one. The real question, of course, is what do we do with no significant arthritis? Well, then we have to ask ourselves a question. The first is, is this patient young and active or older and inactive? Super important. Now, I put 65 on there, but as you all know, that's sort of a negotiable term, especially as I get closer and closer to it. But what I tell you is, is that young active patient or older inactive patient, so consider this patient, one of mine, 74 years old, she knits, she hurts, and it's hard to unload the dishwasher. So she might not have very much arthritis. She's still going to get a reverse shoulder arthroplasty. It's a very reproducible procedure, and for what she needs, this is a very reproducible outcome on her. But again, this is not the side of the algorithm that anybody wants to debate because it's not terribly controversial. What's more controversial, of course, is this side of the algorithm. What do you do with that young active patient? And I would say, well, then you have to ask yourself a question. And the question is, is this patient functional or non-functional? This is critical because just as you saw in my first patient, a patient who has a massive irreparable cuff tear and who does this is an entirely different animal than the patient who does this. So that's the question we have to ask. If this patient is young and active and is functional, well, this is this patient. She's a 48-year-old female. She has pain, but she has excellent function, massive cuff tear, no DJD. She doesn't have any real complaints except her shoulder hurts. Well, if this patient and this patient, we can do anything. You can cut the biceps. That's been shown to be excellent work. You can do a bar procedure, as Matt Ravenscroft has taught us, or what we call the SCR minus. It's one of the acromial or the tuberoplasties, or you can put a balloon in her. All of those things will work because she has pain and you're not trying to reconstruct motion. But again, that one might be less controversial. Now we get to the money. What do we do with somebody who has massive irreparable cuff tear, no significant degenerative joint disease, young and active, and who's non-functional? Well, then you have to ask yourself a question. Is their cuff muscle alive or is their cuff muscle dead? Because if there's muscle, there's hope. So if that cuff muscle is alive, so this part of the algorithm right here, that takes us back to this young man right here, non-functional, but the cuff muscle's alive. Even if he's non-functional, this is the ideal indication for me for SCR. He's got muscle. If his brain tells his infrared to fire, it'll fire. It just doesn't have anything to connect it to, so we have to reconstruct that. That means through an SCR or through an extension graft, and that will work very well. And in our hands, that's been an excellent procedure. Even though SCR seems to be falling a little bit out of fashion, this is an excellent choice for this patient. So this guy gets an SCR plus. We also reestablish on top with the acromion as well as part of our standard gig. So finally we get to the end of this. The massive irreparable cuff tear. Again, no significant DJD, age less than 65, non-functional, but now the cuff muscle's dead. The SCR will not work in that patient who's non-functional. There's nothing to fire. So in that patient, that's this guy. He's a 52-year-old. He's failed three times, gone through an infection stage. We've gotten that cured, and now we've got to get in this guy. This is, I think, the ideal indication for the lower trap transfer because you have to retransfer living muscle, a living muscle tendon unit, to be able to get him to fire. This is the technique that we use. We use four anchors coming across, anterior and posterior, and then a second one medial and lateral for this guy. This is his one-year result, and you can see that the lower trap transfer, and all credit to Basim Elassan, who's taught us this technique. I was a little skeptical at first because this is dead tissue we're putting back in the shoulder. It's remarkably useful at times. You can see how happy this guy is. So when we want to summarize this, again, I think you have four questions to ask for the massive irreparable cuff tear. If they have significant DJD, do the RSA. Are they active or inactive? If inactive, go ahead and do that RSA. It's a very reliable one. But if they're active, you've got to ask yourself, are they functional or non-functional? If functional, give them whatever you want. If they're non-functional, is the cuff alive or is the cuff dead? If the cuff's alive, that's your SCR. If the cuff is dead, then I would urge you to consider a tendon transfer as the SCR. Don't ask me how I know this. We'll let you down. In conclusion, then, the massive irreparable cuff tear remains controversial. There's a lack of consensus on how to treat this condition. There's always exceptions. But I think algorithms can be really helpful in terms of getting us there in terms of the decision-making process. And we still have lots to learn in this area. Thank you very much for your attention and best of luck in your journey. Thank you.

management strategies

massive irreparable rotator cuff tear

active patients

options and algorithms

nuanced approach