All right, very good, everyone. We'll get started with our next session. So this is six-week range of motion as an independent risk factor for non-healing at six months after. Thank you for the introduction. I'm grateful to be able to present our paper here. So we know that retinocular repairs enables rapid recovery of short-term function in most cases. And tendon healing is paramount to maintaining these results over the long term. Rehabilitation is also a key determinant of the recovery process. However, the best post-operative care remains a source of debate. And probably the lack of clear understanding of the healing process and its clinical science contributes to fueling this controversy. The study aimed to analyze the relationship between tendon healing and the course of range of motion recovery during the first six months after a supraspinatus repair. We hypothesized that a greater loss of range of motion in the early post-operative period would be associated with tendon healing. This was a retrospective study from prospectively collected data. All isolated primary arthroscopic supraspinatus repairs for full thickness tears without any significant retraction, fat infiltration, or OA were eligible. The cohort was then divided into groups based on tendon healing. A consistent operative technique was used throughout the study period by one surgeon using a standard double row technique. Post-operative rehabilitation included a period of immobilization. However, passive range of motion was initiated from day one. All patients underwent a standardized assessment before and at six weeks, three and six months after surgery. Recorded data included passive and active range of motion, the VAS for pain, and the constant score. One independent MSK radiologist assessed tendon healing at six months by ultrasound according to Sugaya's classification. Finally, 1,207 supraspinatus repairs were finally included and divided into groups based on tendon healing. Both groups had similar baseline characteristics except for age, which was higher in case of non-healing. The analysis of the course of recovery showed that there was a strong correlation between passive and active range of motion at each follow-up. Six months' range of motion in any direction was similar to pre-op values regardless of the fate of the repair. Differences between both groups were more pronounced at six weeks as they appeared early after surgery and in the absence of six weeks' active range of motion measurements. Thus, the difference between the two groups were the greatest at six weeks and close by six months. And heel supraspinatus repairs, sorry, the course of recovery of heel supraspinatus repairs was characterized by a bigger drop in anterior elevation and external rotation during the first six weeks followed by a subsequent increase during the remaining follow-up period. And the differences were the greatest at six weeks and close by the end of the follow-up. With regard to pain, the evolution of pain was similar between groups up to three months. Afterwards, only heel repairs continued to improve, resulting in a significant difference at the end of the follow-up. However, the overall level of pain and the extent of this difference was very small and probably not clinically significant. Finally, regression analysis confirmed the importance of the early range of motion on the risk for supraspinatus non-healing at six months and passive anterior elevation and external rotation at six weeks as the last age were all independent risk factors for non-healing. Study limitations included in short-term follow-up the fact that these results may not be applicable to other rotative curve tear patterns, repair techniques or rehabilitation, and we weren't able to assess patient's compliance to the rehabilitation protocol. In conclusion, this study highlights the importance of the early postoperative period after primary isolated arthroscopic supraspinatus repairs. In a large cohort with similar baseline characteristics and undergoing an identical treatment, heel repairs had a greater transitory range of motion limitation, with difference being the greatest at six weeks. And the study also identified independent risk factors for non-healing such as six weeks passive anterior elevation and external rotation and age. Thank you for your attention. Thank you, Dr. Martino. Next, we'll have Dr. Kuhn with long-term outcomes of non-operative treatment of atraumatic symptomatic full thickness rotator cuff tears, 10-year outcomes of the MOON shoulder cohort. I loaded it up in the thing. I'll work on both. There we go. Perfect, thanks. I'd like to thank the program committee for letting us present our work and my co-authors in the MOON shoulder group. These are our funding sources, none of which really represent a conflict of interest with the data that I'm about to share. So the purpose of this research was to identify predictors of failure of non-operative treatment for atraumatic rotator cuff tears to help us give some insight into indications for surgery. And this was a prospective multi-center cohort design study. We enrolled 452 subjects and they were given an evidence-based physical therapy program. They were to work with a physical therapist until they could do a home program and we assessed them along their course up to 10 years now. Anywhere along the way when they were doing the therapy, we asked them if they were cured, they would stop therapy. They continued it sometimes for 12 weeks and then anywhere along the way they could have stop and have surgery. We looked at a lot of variables that we thought might predict the need for surgery, including structural factors related to the rotator cuff tear. This is our 10-year follow-up. We have 422 patients now that we followed. 9% of our cohort died before 10 years. We only lost 9% to follow-up. Of the entire cohort, 27% of the patients had surgery. Most of these were rotator cuff repairs, although we did have about a third of our cohort have bicep surgery. Only one patient had a reverse arthroplasty over the 10-year course. This is a survivorship curve. So for every patient that had surgery, the curve drops toward the floor. And you can see first overall, more than 70% of the patients never had surgery along the 10-year time course. If you look at the curve, there's a rapid rate of surgery early in the first six months and that represented 57% of the cohort. And then from six months to 10 years, about 43% of those who had surgery had surgery. So that represents two different populations, we thought. We looked at them independently. The early surgery people had predictors of surgery that included patient expectations. The way this chart is designed is the stronger the predictor, the farther out to the right it is. And so you can see that dot on the bottom right corner is patient expectations. And so essentially, if a patient did not think physical therapy would work, it would not work and they would have surgery early. Activity level was also important, but the retraction of the tendon was also important statistically, but it was opposite what we expected. We found that patients that had smaller tears actually were less likely to have surgery than patients, I'm sorry, patients that had smaller tears were more likely to have surgery than patients that had larger tears. When we look at the patients from six months to 10 years, and we call that having later surgery, workers' compensation and activity level were statistically important in predicting the need for surgery. What's important about both of these things is that there was no feature of the anatomy of the rotator cuff tear that predicted surgery. Size, atrophy, physical exam findings, nothing else really seemed to predict surgery. These are our patient reported outcomes over time. And as you can see, when they start, they're fairly low. They get better with physical therapy. And importantly, they did not change for 10 years, which we expected them to change because we know about half this cohort, their rotator cuff tear should have enlarged over time. But what's interesting is we did not see changes in patient reported outcome scores. There's limitations of this. Our population may have had a self-selection bias. When we enrolled patients, those who really didn't want to have surgery might have been enrolling more frequently. We couldn't measure tear progression. It would have been too expensive to get MRIs on 450 patients. And we really can't state that therapy is a better treatment than surgery. But I think we can state that therapy is a good treatment for surgery, for rotator cuff tears, just as surgery is. So in summary, physical therapy is effective for more than 70% of patients, and it's durable up to 10 years. Early surgery is driven by low patient expectations regarding the effectiveness of physical therapy, and workers' compensation status and activity level become more important predictors for having later surgery. What was interesting is that patient reported outcomes were stable over 10 years, and we really didn't expect to see that. We talk a lot about rotator cuff tears progressing and getting larger as time goes on, but the reality is they may not be important with regard to patient-reported outcome measures. And only one patient in our entire cohort had a reverse arthroplasty, so you can confidently tell your patients they're much more likely to die than need a reverse arthroplasty. Thanks for your attention. Thank you. Thank you. And then next up, we have Dr. Graue with a machine learning approach to predicting rotator cuff repair outcomes. Thank you. I'd like to say thank you to the committee for selecting our paper as a podium presentation, and then also to everyone that is sticking around for the very last paper presentation here. So my name is Brian Graue. I am at the University of Cincinnati, and here is my disclosure slide. First, I'd like to give a special thanks to our team, especially one of our residents, Dr. Catlett, who has done quite a lot of work getting this off the ground and able to be presented. He is potentially in the audience or sightseeing at the wharf. I'm not sure, I've not seen him yet. So I don't have to convince anybody in the room about the impact that rotator cuff disease has on our population here in the United States. It's a very common problem that presents to our office. It's a very common surgery that we perform, and it's certainly something that is ripe for continued research. The disease burden itself is difficult, and retail rates or failure of healing remains very high, even with sound biomechanical repair principles. I would tell you something that's very difficult for me is how to predict how a patient will be doing after surgery, especially if I cannot predict whether or not the tendon is going to heal. It's also very difficult for me to predict whether or not the patient will be satisfied after performing an operation, such as a rotator cuff repair. Tell you, you have this picture on the bottom right where it's pretty obvious that a rotator cuff repair would not necessarily be helpful, but rarely is the clinical scenario that dire. So we thought to ourselves, you know, how can we do better? Can we accurately predict success? And can we offer something practical for both the patient and the surgeon to help guide decision-making? So we took the approach through artificial intelligence via machine learning to figure out if we could answer these questions. And to sort of level set, we would like to kind of offer to the audience machine learning on a basic level uses computer algorithms and statistics to allow for the identification of complex trends and patterns in the data sets that you give it, or that you extrinsically put into the algorithms. Why is this a powerful tool? It allows for things to be compared where standard statistics are difficult because of the vast amount of data that has to be sorted through, the fact that it is nonlinear and rarely normally distributed. Hence, predictive modeling can be very difficult through these types of standard statistics. We are not the first to the party in terms of utilizing predictive technology for the rotator cuff, and we will certainly not be the last. This is very much so in its nascent state and the tip of the iceberg. So we hypothesized that machine learning would accurately predict achievement of MCIDA following a rotator cuff repair, and then hopefully we would be able to develop a clinical app that would be friendly to the clinician. We enrolled prospectively 215 patients. Key inclusion criteria were primary repair only, so no revisions. They needed six-month follow-up, and then we took out massive tears based upon tendon size or number of tendon, and then also no partial repairs were included. Demographics, patient characteristics, MRI characteristics, surgical characteristics, these are all things that we felt were important that would affect the outcome. This is clearly debatable, and this is something that can also be catered in an a la carte method when you're designing these algorithms. And simply put, the way that the process goes for machine learning is there is a data pre-processing in terms of the extrinsic factors. There is then data balancing, followed by feature engineering, predictive analysis, and model training. And we set our MCID to 11 based upon a RUSH study in 2019. In terms of the receiver-operator curve and the different models that we utilized, we were able to identify three separate models that were very effective at predicting MCID following rotator cuff repair in conjunction to those clinical features that I mentioned. And they were the random force, the SVM, and the XGB. You can see all the features on the left, and then on the bottom right, the consistent features. That really affected the outcome in terms of the patients achieving MCID following rotator cuff repair. And the most influential characteristics were pre-op pain, BMI, symptom duration, the presence of an upper border subscat tear, and then also the educational level of the patient. This is actually a fairly easy thing to look at when you look at the shape plots that the algorithms will put out for us as clinicians. And the higher it is to the top and the more to the left it is will tell you whether or not it's going to not allow for MCID to be achieved, which allowed us to create this clinical app, which is still a work in progress, where you can put in these different factors to the machine learning, and it will be able to allow for you to see whether or not the patient has an opportunity to achieve an MCID following a rotator cuff repair. So in conclusion, I think ML models really do offer a promising avenue to predict outcomes following rotator cuff repair. Practical calculators can be developed to aid in patient and surgeon decision making. This is not meant to replace clinical equipos or patient autonomy, and I really do think broader applications are clearly possible. So thank you. Thank you. Okay, three excellent papers. We'd like to invite audience questions at this time. Dr. McDonnell. Question for Jed. It's a great paper, obviously a landmark for us to talk about the non-operative treatment of rotator cuff tears. When you say physiotherapy and the fact that it was durable over time in terms of a treatment, do you have any idea how long these people did their physiotherapy, or did they just do a three-month course and then just go back to doing whatever? You know, they did not do, in general, they did not do formal physical therapy after their treatment. So whatever pain they were having seemed to get better, and then we just continued to follow them. Most of them, like I said, 27% had surgery, but most of them did not, and we don't have data specifically that I can share with you today that showed how many went back and had more therapy sessions, but it's very small. So do you think that some of these people are just naturally, for whatever reason, they're just copers? Like we used to talk about copers for ACLs, they're copers for rotator cuff tears. Yeah, I think you're exactly right. I mean, if you look at patients that have rotator cuff tears, you can see they have hypertrophy in the muscles that are remaining, and my own belief is if the rotator cuff tear extends slowly over time, they adapt quite well, and they don't have a lot of pain with that, and they're certainly not coming in to see you in the office. I mean, if you look at the demographics of it, yes, we do 500,000 rotator cuff repairs per year in the United States, but there are six million people with rotator cuff tears who are operating on less than 5% of all the people out there. So most people are adapting. Thanks, great work. Thanks. Yes, thank you, I have two questions. Jed, did you look at your cohort to see if they had contralateral problems in that tenure? Well, any history of contralateral problems was an exclusion criteria, but we did not do ultrasound to see if they had asymptomatic tears. But no symptoms developed. Did you exclude people who developed symptoms in their contralateral shoulder? It was only the inclusion, when they entered the study, yes. Considering that there's probably big genetic factors, that'd be interesting to see. And then Brian, a question for you. I'm not sure you have enough subjects to really use machine learning to develop an algorithm for that. What's your thoughts on that? So in partnering with sort of our engineer partners, that was a topic of great debate in terms of the number of patients and the potential for error in the ability for the algorithm. So that is what the balancing of the dataset allows through the SMOTE technology that will create then patients with other scenarios as the application is training itself. However, your point should be very well taken, and this is not necessarily the end of our work, but rather the beginning of our work. Yeah, for Dr. Martino, your senior author has published a paper that using a sling or not losing a sling has no difference in the outcome. And now you have a paper that shows that if they have more motion at six weeks, there's a higher likelihood there's a tear. Have you changed your post-operative rehabilitation protocol? Do you just immobilize them for six weeks so they don't move, so they get stiff, so the tendon will heal better? Thank you for the question. In fact, we didn't change our rehabilitation protocol. The study you mentioned from Dr. Lederman, the sling and no sling groups, so this was the, this was made, that was the design for this study. This was always our rehabilitation protocol. And I think both studies, they aren't in contradiction because in the sling study, there were patients with a sling and others with a sling, but all patients, they receive instructions to do passive range of motion exercises and not active during the first six weeks. So I think the immobilization was different between the two studies, but the rehabilitation protocol per se was not different. Thank you. Great, thank you. And in the interest of time, we'll move on to our next session. Thanks again to all our paper presentations. Thanks. We can have our next two presenters join us on the stage. We'll start first with Dr. Lassiter, when to repair and when to replace for cuff tears. Hi, my name is Tal Laster. I was asked to talk on the topic of reverse versus repair in rotator cuff tears, and I've had a good introduction, so without further ado, my conflicts are on the Academy website. So I hope you don't end up this meeting and think that Dr. Laster is over-reversifying America, especially that we know if we're doing this many reverses, there must be a lot of people who died because we found out a lot more people are dying than having reverses. But in this case, I would like to add a little bit to the confusion. So my bias would be that I am a sports medicine doctor who now does a lot of arthroplasty, and so that may affect some of the beliefs I have. So one thing I'd like to leave you with is some of the data that we have that helps guide our decision-making, because it can be confusing with the statistics that we see in the various studies, some of which seem to be conflicting. And so one thing that I want to bring your attention to is the rotator cuff healing index, and the bottom line is that we see that patients who have rotator cuff repairs that are over 70, have large tears, have fatty atrophy in their infraspinatus, return to heavy labor, and have other confining factors such as albumin being low, poor nutrition, smoking, diabetes, and need assistance for ambulation don't do as well with rotator cuff repairs. So we know that we can do rotator cuff repairs first, because if they fail, we get good results with reverse. And then a lot of us as sports medicine doctors said, well, even if that fails, we can always do an SCR, but we see now that less and less shoulder surgeons are doing superior capsule reconstructions. And we have good data that says we don't get different results if we do rotator cuff repair when we bail to an RSA, but you have to ask yourself in this meta-analysis, if we had in this study, we had 438 tears prior to reverses, why did we do so many operations twice? Why should it have been a reverse first if there are that many failures of the rotator cuff repairs? So there's an interesting study Cleveland Clinic published where they studied, they put metal markers in their rotator cuff repairs at the muscle tendon junction, and they measured them with CT scan over 3, 6, 9, and 12 months to see if there's any retraction of the tears over time. And interestingly, they found 20% didn't heal at all, and that 53% of the ones that did heal retracted a centimeter. They said these may be functionally incompetent rotator cuffs, despite them having healing evidence on MRI or CT. Here's a case example. This is one week in the office, I saw these the same day. Here's a 59-year-old male who came in, he had a traumatic tear, he's a handyman, humeral head elevation, large cuff tear, subscaps involved with fatty atrophy, and I think most of us might think we'd repair that, that's what was done in this case, had a repair, unfortunately it failed, and this was in six months, and now he has a reverse. Can we do better? Can we predict this? Here's another patient, 68-year-old male, diabetic, Lipitor, normal DEXA scan, normal nutrition, he has head elevation, he was repaired, had a large cuff tear, repaired, failed, gets a reverse. So how can we avoid this? Are there things we can pick up, machine learning or otherwise, that would help us? Well, here's some considerations I would suggest that you might want to take into account. Smoking, diabetes, and malnutrition, I know they're bad for all healing, but rotator cuff tears particularly, maybe metal is better than counting on soft tissue to heal. Tear size and atrophy, if we have large tears, we'll see in the subsequent data that those are poor predictors for healing. Patient support post-op, and I mean social support, who's with them at home, are they going to have to push themselves up out of bed, or they have to drive, or do they have help at home, can they actually do what's required to rehab a rotator cuff repair? Ambulatory aids, I have a lot of patients who are using walkers when they come in, or wheelchairs. Now I submit that most of us would not want to repair rotator cuff tendons with patients who are going to be dependent on a wheelchair or walker to walk. Then prior rotator cuff repairs, I think many of us would agree that's a good time to consider reverse. And if they have much OA, which often is not picked up on plain radiographs, but maybe an MRI is a good choice. So we know from Dr. Frankel's work that rotator cuff repairs of massive rotator cuff tears do well. He's shown us in his studies that patients less than the age of 60 probably are not good candidates for rotator cuff repair. Patients who have good range of motion can lift their arm over their head, not too much pain, probably shouldn't do a reverse on those. If they had humeral head elevation, probably not a good candidate for repair, maybe a reverse is a good indication. We can't do reverses very well on people with neurologic dysfunction with axillary nerve deltoid doesn't work. So is a reverse, am I telling you that's the golden chalice? No, hardly. Because we know from various studies long term that over time that the results of reverses do diminish. But the rotator cuff healing index that I discussed earlier on, they had a good study looking at repairs, 603 patients, this study out of South Korea, Dr. Kwon, and over two years' time they saw a 24% failure of them to heal. So they looked at the group that didn't heal and the characteristics were these patients were over 70, they had two and a half centimeters of AP retraction, and they had atrophy in the infraspinatus. And if they went back to heavy work, that was an indication they were likely to have a failure. They also looked at bone mineral density and pore density also predicted failure. So they developed ROHE or the Rotator Cuff Healing Index, they assigned points and the points assigned are based on the various risk analyzing their failures. And you'll see that if you have a big tear it's measured in two directions, so you get two points for AP size and up to three points for retraction. So that gives you five points, over 70 gives you two more. And if you have head elevation you get another two, if you're going back to heavy duty work you get two. So they found out if your ROHE score was greater than five, that you had 50% failure of your rotator cuff repair. So that's not too hard to find. This is a group of patients you may want to consider a different option than primary rotator cuff repair. So who's the patient that you might not want to do a primary rotator cuff repair? Well it looks a lot like this, he does heavy duty work, he's over 70, has fatty atrophy and he's going to return to heavy labor. There are other ways to think about rotator cuff repair from a patient perspective. Economics, patient satisfaction outcomes, shared decision making and predictability. Economics, we've had studies to look at that and the whole economic analysis is tough because we don't have good data, we don't have prospective studies. But the study, this paper showed that in this indication, large cuff tears, it was better to do rotator cuff repair. Larry Higgins criticized it, not the paper per se, but for the data that we have because we don't have large databases that can compare rotator cuff tears that are large versus reverse shoulders that are not muddied by other conditions that are treated by reverse shoulders. Then what are the real costs in time to your patient? So in my patients, I look at on the left RSA, on the right rotator cuff repair. We've been shown by Rush and others that you don't even have to go to PT necessarily after reverse shoulder. My patients can drive a car in three weeks. They have less pain than they do with rotator cuff repair and the outcome's predictable. What are the costs to the patients by their surgery? What's the time of incapacitation? How much pain will they have? What's the likelihood of failure of the surgery that you do to them? How predictable is it and can they go back to the sports or activities that they want to do? Most commonly that being pickleball these days. Then a really important paper I thought was Christian Gerber's paper. He looked at shoulder reconstruction determinants of patient satisfaction and he's found increased satisfaction in patients who had no complications. That's of course obvious. Post-operative pain control was well done and they had good abduction. But most importantly he found that people with shoulder arthroplasty had higher satisfaction and more importantly that there were 25% of the rotator cuff repair patients who were dissatisfied with their surgery. And how about return to sports? Well that's been analyzed by Peter Millett and others and had 70% patients return overall. If you look at arthroplasty the numbers are at least as good. Now this is not a compared group. The sports that some of these studies look at are shuffleboard, not maybe tennis or golf. But nonetheless you see you can get good results with arthroplasty for return to sports. So I would bring you back to where we started, rotator cuff healing index and things to consider when we're thinking about should we repair this large cuff tear or should we consider reverse and what patients might that be more appropriate in. And based on the data that I've presented I think we can say that patients over 70 years old have a higher risk of failing a rotator cuff repair, tear size, retraction, AP diameter. If you have infraspinatus, fatty atrophy those are high failures and if they're returning back to heavy work that's a group that's not going to do as well. And then if we look at patient satisfaction which scores are very high in arthroplasty and not so high in rotator cuff repair, cost to the patients, predictability and return to sport I think we find that reverse shoulder arthroplasty does very well as compared to rotator cuff tears of large size. Thanks for your time. Our last session now with Dr. Freehill, rotator cuff repair augmentation options and techniques. All right, well, thank you so much for the opportunity to speak today. It's a great honor. I'm going to talk a little bit about augmentation options and techniques. My disclosures, now two of them are relevant in this particular case. The first company I have spoke on behalf of one of the products you're going to see. The second company, I am an unpaid consultant, but I am doing research and they are providing that ability for me. So two types of augmentation, onlay and bridging or interposition. When you look at early work from Allison Toth and Duke, she did the human acellular dermal allograft, more of an interposition, but had outstanding results. Another study out of the Duke group, more of a systematic review, looking at graft augmentation as well as interposition, did show us there's lower retail rates, there's improved ASCS scores, but rightfully so, they said, hey, we need more studies. We need better methodology studies. We need to keep looking at this. I took this study simply because when you look in the literature, it's hard to find, you know, a conglomeration of all these. You have some randomized studies, you have a lot of case series, but this actually took everything. And I just thought it was interesting to see where are we now and kind of along the same lines, it looks like there's a decreased failure rate, it looks like there's small improvements with pain and function, but, again, the conclusion, there's a paucity of rigorous studies here and we need that moving forward. More recently, this study came out, was published in ANA just this year. Now if you get, again, you got to look at the details and this looked at randomized studies, but only for large tears. And if you look at the control group versus the augmentation group retail rates, it does appear better in the augmentation group, but as an editorial pointed out, you know, there were some problems here. A couple studies were left out. The search words were only augmentation, so you've removed the interpositional group. They only focused on one size of tears and there wasn't much on the adverse events, which we're all interested in. So we're getting closer, but certainly not there. So let's pivot a bit and talk about what are some options of when we can augment. So partial tears, bursal-sided tears, articular-sided tears, intratenderness, massive tears, massive tears or large tears that you just don't like the quality of the tendon or you're not happy with your repair and in revision settings potentially. We all know the literature is very ripe with this. Partial tears and small full thickness tears, they're going to progress, generally speaking, and with that, symptoms will arise as will degradation of muscle quality. I think you got to get back to the basics here with the classic Clark and Harriman study. Remember, we have five layers of the rotator cuff. I don't think we talk about it enough. We know that layers one and especially two is your good longitudinal structural integrity collagen. As you get closer to the articular side, it's more capsular. That makes sense when you start to think about how we see much more partial tears on the articular side, right, because just of the stress strain. But I think it's important because this lends us a little bit of should we be doing a scaffold or an augmentation and when should we do it. So different options. We know there's onlay scaffolds out there from various sources. We know that the long head of the biceps tendon can be used in various fashions such as a bio-SCR or taking a segment of it and flattening it and allowing that to be an augment. And we all know that there's a lot of different options for a cellular human dermal allograft. Questions arise. If you put scaffolds down, especially of the xenograft variety, is this causing inflammation? This study in JSCS last year did show that almost 50 percent in the scaffold group had a cortisone injection. Now, with that being said, 30 percent of the control group also had it and there were some slight differences in the two groups with regards to repair versus debridement. But still, I think if you look at a systematic review, again, not a lot of studies. But this was interesting because when you looked at the xenograft group, they did have more complications and almost all of these were in the fashion of bursitis. Now, is that because of what is being utilized to hold that scaffold down? A lot of times PLA or is that the graft itself? And I think more work needs to be done to get there. Back to Allison Tosfork, you know, we know the porcine dermal allograft shows very good host cell infiltration, collagen reorganization, vascularization. That's what we want. When you start looking at the human acellular dermal allograft, it's more varied, right? So I don't know if that's more of a scarring effect onto it or if you're truly growing into that. But it seems that some of the xenograft scaffolds with limited studies do have some revascularization and some cell infiltration. So I think we're still building there. So repair versus straight augmentation, bursal-sided, partial or pasta, intratendinous. Here's a patient of mine, 37-year-old CrossFitter. We all have these patients. Looks like an intratendinous tear there. She failed nonoperative management. I think a lot of us would agree when you put the shaver there, that capsular layer debrides away very quickly. These are really more high-grade pasta tears if you see that intratendinous. In this case, we talked about options. Bursal-side looked okay. I placed a scaffold on it, and that was at four months. And what kind of tissue is there? I don't know. But does it look like the tendon looks improved at the footprint? It appears so. Question always arises, how can you put something on a bursal side and now be having improvements or healing on the articular side? I don't know the answer. My best understanding of this is Edge eToy's work that used this model to place two millimeters of tissue on the bursal side. And maybe it acts almost as an internal brace or something that shields the stresses that's seen on the articular side. It's probably not healing in normal tendon, but maybe scar tissue. But that would be how I would describe that. Another example, bursal side, remember, layers one and two. This is the really good collagen. If you see low levels of partial tearing on the bursal side, I'm pretty quick to pull a trigger here. This is that same case, and it matched up pretty well. Again, am I going to take that down? If you look in the literature, and I'm sure a lot of you have, there's not a lot of great techniques for bursal-sided tears. So in this particular case, I thought that this was a great option. He came back. You know, again, he told me up front, I need to get back to work quick. Came back five months out. Had bursitis. I thought it was a great opportunity to get an MRI, and you can see, again, the tendon looks pretty good. It looks healed on that bursal side, but what on earth is going on with the signal at the musculotendinous junction? It's probably not retorn there, but I did take him back to surgery to do a decompression and just a debridement, and that's the tissue there. So it did seem to have some healing of tissue and some vascularization, and I think that likely what's going on is those staple anchors or that PLA is causing some localized inflammatory responses. So since the time of that kind of big conglomerate, have we had some more scaffold studies? Yes, it does seem, compared to take down and repair, that they hold up if you want to utilize that. How about augmenting full thickness large and massive tears or poor quality tissue? My go-to choice, if that long head is intact and it's of good collagen quality and attached well at the superior labrum, I'm incorporating it, and I lay it down at the area where I think that there's the least amount of tissue. It's kind of an intraoperative decision-making event, and then I'll tinnate distally, but we should really utilize that if we can. It's free. Going back, this has been performed for a long time, but it's kind of regenerated the interest. Most of some of the work more recently was technique-based, but now we're starting to see some of the outcomes come out, as well as one of Larry Field's papers that show this bio-SCR showing really good outcomes. How about when you have a full thickness tear like this that's pretty thin tendon? Try to bring it together, do the best you can, but I didn't feel 100% confident here, so this is a case where I would add a scaffold. This is a different type of scaffold I'm utilizing. I think the integrity of this is very good. It's a little more resilient to how you can place it and what you can do with it. In this case, I'll place a small 1.7-millimeter anchor, all suture laterally, and just do almost the equivalent of a traditional double row. Just get it down and let it parachute down on itself. We know that Buddy Savoie's work won the Herodicus Award a couple years ago, and this is large and massive tears, 96% healing, so there was no control group, but I'll tell you what. If we can get improved healing rates in this kind of setting, that's a benefit that we should be thinking about. So in conclusion, I do think at this time, with more evidence needed, of course, that articular-sided and bursal-sided tears can be treated with scaffolds in certain cases. You don't have to take down the healthy tendon. You don't have to make a lot of passes through the healthy tendon. In the large and massive tears, bio-SCR, long head, first choice. If you get your repair done, or in a revision setting, you don't like the quality of the tissue, I think that a scaffold of your choice is a very good option. Thank you. And I do want to put a plug in for National Shoulder and Elbow Week. If you're in one of these eight areas, please attend. It's a great cause and makes a lot of money for research. Thanks. All right. Great talks, Dr. Lassner and Dr. Freehill. Can we have Julie Bishop come up, Dr. Waterman, Dr. El-San, and Dr. Romeo. Thank you. All right, well, we're good. So we would like to thank you for staying until the bitter end. We know you're tired and hungry, and it's been a long week. But Brian had to show his amazing slide with a video for his opening slide, so we had to see that. All right. So first case is an active 50-year-old male. This is my patient. He fell dirt biking 15 months before he saw me, had a traumatic cuff tear, went to an outside hospital, had two surgeries. He had one two months after the injury, and then he had another surgery five months after the injury. And now when he came to see me, he is 10 months from his second surgery, and he was told his repair failed. His complaint is pain and weakness away from the body. But I have to be honest with you, it's not horrible pain. It's not keeping him up at night. But it's uncomfortable, and he has a difficult time with things out away from his body. He is an intense human being. I'm the fifth surgeon that he's seen, and he said that all paths led to me and I'm going to fix him. He was told revision cuff. He was told reverse. He was told traps transfer, and he was told SCR. So here is his range of motion. Incisions are healed. No wound healing problems. He had no obvious atrophy. Here's his range of motion, good forward elevation. When he comes down by the side, he has decent external rotation, maybe just a tiny lag. His subscap is intact. And he can go behind his back, and he can lift his hands off his back. So here are his x-rays. And in the interest of time, I'm sure you can all tell that those x-rays are good. We're going to go on to his MRI. So Michael, what do you think about what you have heard and what you've seen so far? You know, I'm pretty surprised at how good his exam is for that kind of history. I mean, you can see a re-tear here, and he has a little bit of external rotation weakness, but he's five. He's two months out from the latest one. Ten months from the second one. From the second one. And remember, he's 50, and it started traumatically. So he had no problems and truly had a traumatic dirt bike accident. So why do you think he looks like this? What's his strength? It's four out of five in ER, and honestly, probably five minus in forward elevation, more pain inhibition. Yeah, so, you know, I mean, I'd look into this a little bit more, but generally speaking, he does have a little bit of a lag. You look at that infraspinatus, It's got some fatty infiltration. He's obviously very active. This is going to go downhill, so my if my thoughts initially here. I'm sorry, say that again. My thoughts initially here, you're going to need to do something that has some power, some motor, so I'd be leaning towards lower trap and I'd utilize that long head that's still there. Bassem, what do you think? Well, does he have AR lag? What did you say? Does he have an AR lag? Not really, maybe just a teeny bit, but not really. What does he want? What does he want? He has great motion. What does he want exactly? So that's a good question. This goes back to Jed's paper from Moon. What he wants is his MRI to not show a tear, okay? That is what he is focused on. His body has a problem and it must be fixed. That is truly what his issue is. Yeah, but this this is exactly why I asked this question because when we we don't see this patient in our clinic as often, you know, for someone to be intense, you want the MRI to be and will be very, very, even though I love to do lower trap, I would be very cautious to operate on this guy because of this. And Tony, what are your thoughts? My thoughts are the following. Number one, this patient's never going to be completely happy. Number two, he had a tear before this injury. He has more atrophy that you would expect, so he probably has an acute on chronic event. Number three, the failures that he's had in such rapid succession means he's completely non-compliant with his post-operative rehabilitation. It will continue to be so. So with that in mind, you can offer him a procedure to try to help him improve a little bit, but I think you're really dealing with a personality problem more than a rotator cuff problem. And then Rob, any other questions or thoughts? I mean, I think that I would approach this believing that his original injury was, you know, was truly acute. I mean, I wonder why. Maybe he thought he was a quick healer, you know, rehab compliance, you got to sort all those issues out. I'd like to see parasagittal imaging that was T2 to see, maybe this is a case of pseudo fatty infiltration. I would be okay trying to get something out of those muscle bellies. I mean, I wouldn't call that dead muscle and just, you know, write that off. I would, if I was taking this guy to surgery, I'd see what I could get out of his tendon and probably repair and augment if I could. Can you help define the external rotation lag a little bit better? Does he have a loss of rotation or movement in that direction or is actually weak in external rotation? I see the MRI. So what I would say is when you put him, here, hold on, there we go. When I put him all the way out at about 40 of ER, he just lags slightly. But you'll be able to see, I mean, he clearly has a negative horn blowers. And then when he comes down by the side, he has a hard time keeping his elbow in. But that's what he can do actively. I could put him a little further and maybe he might lag a little bit. But that's it. To me, I mean, if you're going to reoperate on him, it looks like you're going to want to do some type of augmentation with tissue or a lower trap transfer for this individual. And then before I show you what I do, Gene, final thoughts. He actually said, I don't want you cutting up my back and I do not want a lower trap transfer. Perfect. That takes that off the table. So I share Tony's concerns. I've had several patients like this where they're in their 50s. They think that they're still 25. They're still trying to do a lot of heavy weightlifting overhead, especially. And so I think that the expectation management here is going to be the biggest challenge. I don't know that we necessarily make him that much better than he is right now with any operation. I think we stand to open the door to a lot of complications. That being said, you know, potentially trying to do a partial repair as well, maybe with an augment on top of it. But I don't know that I would necessarily pull a trigger on a tendon transfer just yet. All right. Well, here's what we did. So this is what we saw interoperatively. And Michael Freehill's talk, he just knew that I had this case. So the one thing that I thought was interesting is after two revision surgeries or two cuff repairs, he still had a really nice bicep. So we did use the biceps as a bio SCR. And then I did do an SCR. I totally understand it's not a very common thing. He doesn't want a trap transfer. We're not doing a reverse. And there's a chance that it'll still be intact on the MRI. He needs something intact on the MRI. And so here was just the video of what we did. He did have some infra. It wasn't great. I was able to put one posterior anchor and bring up a little bit of the infra. There's his biceps in the front. And then what I could bring up, I brought up to an anchor in the back and then side to sides to the posterior aspect of the SCR. And the hope is that on an MRI that he's already insisting that I get it six months, this is still there so that he knows he's okay and his mind can move on. So Tony, what are your thoughts on this? How do you think it's going to go? And are you going to get an MRI? You know, again, the problem with this panel discussion is that we're trying to talk about rotator cuffs and education rotator cuff, but we're dealing with a patient that's pathologic. But we all have a lot of pathologic patients. I understand that, but that doesn't really help us deal with what we're doing with the rotator cuff. I mean, whatever I say, this person could say something differently and change the outcome because of his psychology, not because of the cuff. I think what you did is reasonable. I think that that individual didn't want it. I'm not completely convinced how much of a lag he had versus some just some stiffness of his shoulder, but let's say that he had a little bit. If you get some repair with the superior capsule reconstruction in this individual and he's compliant with his post-operative rehabilitation, he can get a very good result. And so I think that was, including the biceps, is perfectly fine. So I think what you did, from the purposes of the pathology and the purposes of managing the rotator cuff, was a very good selection of indications. And if he was not pathologic in terms of his personality, I would predict at six months you would have a very nice-looking MRI. Julie, I started taking cultures on these, you know, two prior surgeries, 50-year-old guy, you got the graft in there based on Pascal's data, and I just think, you know, that seems like a reasonable thing to do. That's a good thought. All right, we're gonna move on to Brian. He probably did well. What'd you say? He did well. He's three months out right now. He has actually been compliant, so he's calmed down. I don't think he is that crazy, but he was made crazy by what happened to him. But what is well? When you say he did well, he was well. What is well for me? I'm not understanding. I'm not kidding. He was here, he was here. What is well exactly? He hasn't had a complication by three months, and he has well. That's well, okay, good to know. But we still need time. Hey Rob, if you took cultures, because I think that goes through our mind, especially with two failures, but if you take cultures, would you do that before you, you know, you're gonna put a graft in, and you take cultures, and you hold those for 14 days, and it grows out, see acne, like what's your game plan now? I've just kept them, kept them on oral antibiotics, and then I don't think, I don't think that I've had any since I started doing that routinely. Go, I think they've all been negative, but you know, I would send them. He's not stiff, he's had no drainage, it's not an infection problem in him. So I think you can do that, and if he grows some cultures, you probably would have grown cultures if you just put the swab in the air. That's not what Pascal's data shows. All right, so I'll see your unrealistic pathologic patient, and I'll raise you a real external rotation lag sign. You can see positive hornblower here, and this gentleman, down at the side, he's not doing so hot. You can see he's got a notable social history. He's a rehabilitated smoker. Ten beers, four shots, I'm not sure the chronology of that on a general week. You can see his range of motion is reasonably well maintained. So 53, right shoulder, dominant, he's a contractor. Tony, what do you think about this one? Is there anything other than what Bossum's gonna offer that's gonna meet this guy's needs? I mean, if you listen to Tal's talk, you put a reverse in there if you wanted, but that's not what I would do. And I think this is a very reasonable indication for what Bossum has taught us in terms of managing his indication. You hope that you can repair part of his cuff, and you wonder if maybe this is one where you might add some augmentation to the cuff, but the results have been fairly good with just the lower trap transfer in the right patient. So that would be what I would be leaning to based on the information that we have. Jean, this is a senior level officer. Imagine that, military status. What's your proposal that could get them back to function? I think we all know that senior officers don't actually have that much, you know, physical activity that's required of them. So, but I do think that the lower trap transfer would be pretty reasonable in that population. That's right. Rob, anything you'd do? I think lower trap's reasonable. Bossum, talk to me. Is this the ideal patient? I will do SCI. I'm just kidding. Perfect. Honestly, this is a perfect, perfect, like we were just talking about it. You have full flexion, you have abduction, and usually when you see some of the, actually you see some posterior subluxation, these are perfect for lower trap. So Bossum, any contraindication with the subscap tears and lower traps that you've done? No, repairable subscap should not be a problem, and irreparable, then we do something else. But no, it's not. So I think we'll blow through that, and this is just some of the arthroscopic evaluations. Bossum, as we talk about this, what, how are you managing the biceps in the face of a lower trap transfer? Are you preserving that? Are you incorporating that in? Are you adding any patch if there's tissue insufficiency up top? Patch, I'm not at all, because we showed in a number of patients, when we went back, that the shoulders were sealed completely. For the biceps, you can add it if it looks like, you know, you want to do biceps. If there's no pain with the biceps at all, sometimes I don't touch it, but if it's subluxated, I just notice it inside. Tony, anything different you do? No, I've listened to Bossum. He's taught us this very well, and I've been very impressed with the results that we can get in a variety of patients. I am pretty ambitious about spending time trying to repair whatever part of the rotator cuff that I can, because I do believe, even if it doesn't look great, if you can bring that infraspinatus up some, and you can make sure you get that subscapularis secured if you need to add the biceps to it, I feel that that just really helps solidify the value of the lower trap. So I don't just kind of blow through it, just clean it out and put the lower trap. I will try to do everything I can to get a nice solid repair of the tissues that he has, and then put the lower trap in place. Mike, position of fixation, and how are you rehabilitating this individual? Position of fixation, I bring it over anterolateral. I mean, I try to follow what Bossum's done as well, bring it anterolateral as much as I can, fixate it second, you know, and then I keep them up into some abduction and external rotation, and go slow. Is there a limitation that you'll place on their function upon full return, Bossum? Late, when they're healed, no. Like, when they're healed, they're fully functioned. They can do whatever they want to do. You mean later, right? Once they're healed. I've had trouble getting patients past significant work above shoulder, so if you do a work-related injury, they can go up to a medium physical demand below shoulder level, but it's really hard to get them above medium physical demand above shoulder level. That's true. If you have a construction worker, I tell them that we're doing this because of every other aspect of your life is going to be improved, but you need to have plan B because at six to nine months, we're going to be looking at another job. Great feedback. Obviously, hard case is, I think, in the interest of time, and so as to not upset the presidents and the program chairs, maybe we'll turn it over. How did he do? He did fantastic. He is incredible. In fact, I will show you. This is actually his six-week post-op, and you can see early restoration of external rotation, which is quite incredible at such an early stage. Yeah, if you haven't done this operation, it's really remarkable. Bossum deserves a lot of credit for shedding a light on how much this adds to treatment of this particular individual. Yeah, thank you. A round for our panel. Thank you very much for our experts, and we'll turn it over to the presidents for closing remarks. Thank you. Thanks very much for everyone who stuck around. I really appreciate the program, the speakers, program co-chairs. Thanks very much for a great job, and it's really been fruitful for the ASCS to partner with AOSSM, and Dean, thanks very much. Yeah, it's been a real joy, and to do this together, I think we're better together, and this is just the start of more collaborations going forward, so thank you all for sticking around. Everybody, safe travels home, and thanks.

rotator cuff injuries

advanced treatment options

patient preferences

surgical techniques

post-operative rehabilitation

augmentations

challenging patients

lower trap transfers

superior capsule reconstruction

biceps tendon management