I'm going to cover some cases related to irreparable rotator cuff tears in young patients. Again, if there's questions, feel free to interrupt, let us know. And we'll be going through these and then getting on to the next subject. So I'm at The Ohio State University. And young patients for the cuff world is a little bit of a, it's not your teenagers usually unless there's some throwing-related pathology. It's primarily getting into the 30s like the arthritis. So starting off with the first case, this is a 43-year-old. He's a laborer presenting with pain and loss of function. He, as many patients with bad cuff problems, had had prior surgery. And he had a scope and a rotator cuff repair six months prior. He had good function, just pain going into the surgery. And the MRI report, I never could obtain the actual preoperative images, but the report suggested a partial thickness, rotator cuff tears, some biceps and labral tearing. He did have normal x-rays going into surgery. He had a normal postoperative rehab, sling six weeks, PT four months, not getting better. When he came into the office six months out for a second opinion, he had good healed incisions. He did have atrophy in the infraspinatus fossa, which was notable. And he had a profoundly limited range of motion with active external rotation to negative 20, passively out to 30. But there was a profound lag, so his arm would lag right back in. Forward elevation was relatively preserved at over 100, 110, and his subscap was intact. And so this is a bad shoulder for a laborer. He had no ability to return to his line of work or really anything else. Exam showed one metal anchor from something along the lines of a push lock, otherwise fairly normal. And this is his post-op MRI, but this is the MRI at the time he came in. So let's see if I can. There's a void in the cuff there. But as you get to the supraspinatus, you see that's intact. So it's more of a posterior tear. I think having other views, orthogonal views, is helpful here. This the same one? Yeah. All right. I'll try to pause it. Okay. So to orient, this is anterior, this is posterior. Supraspinatus intact, subscap intact, tear in the infraspinatus. As you get over here, you see some atrophy of the infraspinatus. And so this patient basically has an irreparable infraspinatus tear at this point, or at least concerning for irreparable. He has no arthritis on the x-rays. He's a young laborer with profound loss of external rotation. Can't even actively externally rotate, plus some stiffness, because I passively could only get him to 30. So for the panel, obviously not ideal situation, and his shoulder is far worse off than before his first surgery. So what do we do at this point? What are the problems we're trying to address, and any thoughts on approach? The loss of forward flexion and abduction, Greg, do you think that's coming because the shoulder's no longer centered and balanced, that he's not able to get past 100 degrees? Yeah. I think that he's lost substantial external rotation strength. So as he tries to forward elevate, he can get up there because he's a strong guy, but he has lost that posterior force couple. Yeah. So, I mean, I think this is a bad problem because he's 43 and obviously can't work, and you said he's basically actively at a negative 20, so he can't even get his arm to neutral, which is a huge problem for daily life, right, for just having a cup of coffee. Tough options. I think in this person, if he's up for it, and obviously he probably would be, I think you're looking at a tendon transfer in him, would probably be my thought. Yeah. I mean, to me, this guy's, so I totally agree that the loss of external rotation is extremely debilitating, even if you have preserved elevation, because it, in a patient like this, where with that severity of external rotation loss, like he may not even be able to get his hand to his mouth, because every time he raises his arm, his arm falls down, because there's nothing at all in the back. Yeah. If he needs to drink a beer, his beer's going to fall on the floor. Right. Exactly. Yeah. Yeah. He's the kind of guy who needs a straw in addition to a tendon transfer. Yeah. So to me, this guy's an arthroscopic lower trap every day of the week. And I think the question is, when you do that, do you also try and repair the infra, you know, are you trying to take your graft and completely resurface over the top and connect it to the supra? I think there's a lot of questions about how you do that procedure that are still, I think, being ferreted out. But I think for this patient, that's by far the best option. Yeah. And I think that's important to recognize, that profound external rotation loss, because this won't likely get better with an SCR. This won't likely get better with an arthroscopic biceps tenodesis and debridement decompression. Because he is lacking that active motion, unless that's somehow pain-related, which we didn't think it was, given the scans and everything. You have to restore some sort of a posterior force, and a tendon transfer is really, even a reverse, which you wouldn't do with no arthritis, et cetera, is very, it's more unreliable in terms of restoring that external rotation. So. Let me ask you this, Greg. So you, to me, the most important piece of information to present is that his active forward elevation is 110. So let's pretend he comes in and his active forward elevation is, you know, 50, it's 40. He's pseudo-paralytic. Does that, does that change whether or not you would do that tendon transfer or no? At 43, I might still try the tendon transfer. If the rest of the, if the subscap looked good and hopefully getting that tendon transfer to get his elevation up to 100, but I don't know if there's anything you're going to do for this guy that's going to get him back to manual labor. If he's in his, I don't know the number, but if he's a little older, 50s, 60s, I would be doing a reverse and either lateralizing him a lot or doing a reverse with a lat transfer. How about you? Yeah, no, same, I've, I would probably still do the lower trap, but I'm a lot more hesitant in terms of recommending it because my outcomes for restoring pseudo-paralysis have been really only 50, 50. And I think that matches the literature. What do you, what do you, what do you think, Brandon? I agree with Greg. I think probably the age where I would start looking into a reverse and same time doing a lat transfer and I do lateralize quite a bit on the reverses nor I've definitely started to push, you know, depending on what system you use, I use the arthric system, I lateralize on based on the glenoid side. So I'm two to four millimeters in the glenoid and then four millimeters on the glenosphere to try to gain some of that back. But I agree, if it's really that bad, the external rotation usually have to do a transfer in addition to the reverse. But if he's in his forties, I would still try it. You just have to be honest with them and say, this may not work. And if they say, listen, I don't want to go through, he's already been through one surgery and he says, I don't want to go through another surgery where the results are 50, 50, I just want you to take care of this. I mean, that's certainly his option. But at 43, putting in a reverse and a later, you are hesitant about that. All right. So we went with a scope here and as mentioned, planning for tendon transfer. So some scope pictures, subscap was intact as we knew. No significant arthritis, just a mild kind of fraying, softening as expected. This is a posterior view. So you see some of the intact supraspinatus in the back and then there's this big hole in the cuff posteriorly, which is iatrogenic essentially. So that's again, that hole in the back where the infras should be. This is a lateral view showing the glenoid there, the humeral head, and then where the infras should be. He had some inferior kind of teres minor intact, but this big void at the infraspinatus, which was his prior repair, unfortunately, which didn't heal and got worse. So we pulled on this, couldn't mobilize it enough to get a repair and the tendon quality was very poor and therefore we elected to do tendon transfer. As Peter mentioned, lower trap is a great option. In this case, we did a latissimus dorsi. I don't really have a strong reason to pick one or the other. I've had both be successful for the majority of cases with this situation, which is luckily not a ton of cases. This is the lat. The lat has a huge muscle belly, nice long tendon excursion, which is some of the benefits of it versus the lower trapezius. And this is it being delivered from the posterior incision out to the rotator cuff incision. You can see that tendon has very nice excursion to reach up to the greater tuberosity. The lower trapezius is coming from more posterior vector, more in line with the infraspinatus, which is one of the potential benefits of that. And so that's the tendon coming through, which was then repaired with anchors. You can do the upper portion arthroscopically. It's a lot of suture passage in this one. We did it open. He also had a license of adhesions, as I said, he also had stiffness in addition to his profound loss of active motion and a biceps tenodesis because he still had a biceps after that surgery. So one year post-op, he had reversed his external rotation. He could get out to 30 without a lag, and he had improved forward elevation probably because the forced couple was more restored. And so he was happy, but not back to the occupation. I don't think anything we could have done would have had a chance of that. So lat transfer, Christian Gerber was one of the pioneers of this. Patients with good subscap had good restoration, but only 80% of their shoulder function. You take the latissimus off of the humerus and tunnel it under the deltoid, secure it up by the rotator cuff. This is a series showing the long-term follow-up at nine years. Patients had improvement, but this is not giving them a normal shoulder. So there's still some pain, still some limitation. Failure rate was 10%. In this study, only 19% were pain-free. Risk factors for poor outcomes, prior surgery, often that's nothing you can do about. Mass atrophy of the teres, because that's some intact native cuff that's helping that lat to do its job. Subscap insufficiency, because you're not doing anything to address the front forced couple. Pseudoparalytic, as Peter mentioned, and restricted passive forward elevation, that profound stiffness. And these probably would cross over to the other tendon transfer option, the trapezius. Trapezius is a great option as well, a newer kid on the block, so to speak. The lat is coming from a more inferior vector, so it's not as good for pure external rotation. The lower trap has a better line of pull. And so this has been pioneered by Bossom, Elassan, and others. It does require the use of a bridging Achilles tendon allograft to reach the excursion, because the native tendon won't reach. It's actually a fairly short, but pretty satisfying tendon. So you route this through the infraspinatus up to the rotator cuff and secure it open or arthroscopic. The arm is in quite a bit of external rotation while this is secured, because the allograft is going to tend to stretch out. And I put them in like a posterior stabilization brace afterwards to try to let that thing scar in, at least get them some external rotation by tenodesis effect. The outcomes show that, at least for Elassan, the outcomes were quite good, 97% improved. They had better improvement if they had intact pre-op forward elevation, as Peter mentioned. And they did have improvement of external rotation. That's the main reason why you're doing these transfers, is try to get them external rotation when that's profoundly deficient. I think other options can be very successful for a painful shoulder with an irreparable cuff or somewhat limited forward elevation with good external rotation. I don't think this is your go-to for me. So any final thoughts on that one? I don't know of great comparative literature on the two different transfers. Certainly the lower trap is the most popular at this point. Yeah, I mean, at this point I don't think there is any comparative literature. That's probably coming at some point, probably via meta-analysis, to be honest, because I don't think anyone's doing both of them. And to be frank, because everyone I know who's did the LAD historically and has tried the lower trap is usually switched because the LAD is a substantially harder operation. It's in an area we're not as comfortable operating. It's definitely a bigger dissection. It's much easier to do the humeral portion of the transfer arthroscopically with the lower trap because it's just that thin little graft and you can fix it with two knotless anchors. It's pretty, I mean, it's easier than the cuff repair to be honest. So it's just the harvest. And once people come comfortable with the harvest, they realize, oh, like I can do this beach chair and it takes about an hour and 15 minutes, you know? Yeah, I think that's probably the biggest reason that people have switched is that set of reasons, but I don't think there's any compelling outcome data comparatively that suggests that other than anecdotal, so. Absolutely agree, yeah. All right, any other thoughts or questions before the next case? So we're getting a little younger on the cuff. This is a 38-year-old. Luckily, she's a teacher, not a laborer. Acute on chronic shoulder pain from folding laundry, so it got worse lifting the laundry. She's had two shoulder surgeries. She thinks one with a scope, one was mini open. She never really did great, always had pain and some weakness. And on examination, the patient had some atrophy, both supra and infraspinatus fossa. She had well-heeled incisions over this shoulder. External rotation was 30, so she doesn't have that profound lag like the last patient, fortunately. Slight lag, passively to 50, actively to 30. Forward elevation is in that middle zone, about 60, so she has some forward elevation, but not great, depending on your definition of pseudoparalysis. Any thoughts on where active elevation of 60 with preserved passive leaves you? Is that different from active of 30 versus 90? I think 90 is a good number. I think when you start to get below 75 to 60, I think that's a problem, so I don't think there's much of a difference between 30 and 60. I do think there's a difference between 90 and 60. I think the difference between 30 and 60 is how well-functioning the patient's scapular thoracic joint is. I think that whether it's 30 or it's 60, it's still pseudoparalytic with regards to glenohumeral joint, so that's all that matters. And I think 90 has more glenohumeral joint motion, so I think that's something to keep in mind. Patient had good subscap in this case, and so we'll move on to some images. Brandon, what do you think? So, starting to develop a little arthritis there. It looks like you have a small inferior osteofender, maybe that's just the glenoid in the back that I'm seeing, can't tell 100%. Certainly starting to come out the back quite a bit. That axillary makes me very nervous in somebody who's 38 years old. Or I just have the same x-ray text as you. Not at the Ohio State, now that you've coined the term the. But no, I think that axillary is probably what makes me the most nervous in this patient. Yeah, but I think there's, beyond that, there's already some signs of remodeling superlaterally, there's some rounding of the tuberosity. You know, while there's still preserved acromiohumeral distance, you know, you worry in this patient that dynamically there may be some acromiohumeral contact, and some of that acetabularization that we see in the more severe varieties of rotator cuff terarthropy, because there's definitely proximal humeral migration, and there is not colinearity of the inferior humeral articular surface and inferior glenoid articular surface. So I think that's great observation, so definitely developing some superior humeral migration, glenoid humeral arthritic change, and she's 38, so this is not ideal. Any thoughts, or do we need some advanced imaging? I would definitely get advanced imaging. I think it's gonna be a problem, but we'll see what it looks like. All right, ask and you will receive. Here's the MRI coming through, some thin cuff, maybe anteriorly, not much superiorly there. Not a lot of tendon remaining. There's definitely some muscle, but there's no tendon. So not much tendon there, perhaps consistent with history of prior repair. All right, sagittal coming through here. Any thoughts on that one? I mean, I think it's interesting if you look at that sagittal if you look more laterally, then you can see what I'm talking about with the cranial humeral contact, that there likely is a cranial humeral contact in this patient. You see how close they are? Even though on that grashy x-ray, it looks like there's preserved distance there. So definitely, I think there's a couple things to note here. Number one, there is pretty clear hypertrophy of the teres minor. That hypertrophy signals chronicity of the infraspinatus tere because she's trying to compensate for that. So the laundry didn't do it here. That's a bad sign, exactly. That's a bad sign for chronicity of this tere. That's a lot of fatty atrophy. It's very easy to see how demarcated they are. Actually, I hadn't seen the teres look that big before. There's no way you're gonna get any type of repair of any of those tendons in this case, especially with the lack of tendon being there. So you have to discuss other options with them. So I'm sure you have a list. So we have a good subscap here, which is one thing going for us. And so, you know, they can try physical therapy, of course, and so forth. This acute exacerbation, maybe they can calm down from that. There's no acute tere here, certainly. And if they can get back to their baseline, then there's no reason to rush into surgery on this for me. But certainly, there's not anything left to repair in terms of the supra and the infra. And I don't think this view adds too much. All right, so she has a re-tear or a chronic acute on chronic tear, mostly just a chronic tear. Some glenohumeral arthritis, limited elevation. What do you guys think in terms of options? This is a different person's shoulder. Probably looks about the same though. I think you have a couple options. I think you can consider doing an SCR. So trying to depress the humeral head statically and hoping that some of the muscles around can help balance the shoulder a little bit better, the subscap's intact. The infra doesn't look great or isn't there. So I think it's probably not gonna do great with that, but it's an option. The balloon spacer is certainly an option. Some of the results from here have shown good results, but a new study out of Europe is showing that maybe it's not so great. So maybe we shouldn't be jumping to the balloon quite as frequently as we're doing. There's some debris that it can leave behind and the question is, obviously, it dissolves pretty quickly. So it may not be the kind of answer for all of these problems. And then you can certainly consider tendon transfers, but you'd have to do so much in the way of tendon transfers to get the shoulder back to normal. I don't really think that's a viable option. And honestly, even though she's 38, the consideration for reverse comes out here. And she's had a couple of surgeries before. For me, I don't think she's gonna do great from an SCR. I think if you don't have any infra there, I think it's not gonna do that well. And so maybe you could do an SCR with a tendon transfer to compensate for the infra, but I think your more reliable option is gonna just be a reverse. Peter, would you just do the reverse here? I think it's a discussion with the patient. Honestly, and I hate, I always use that escape, but I do think, I mean, I've had this patient where we've talked about the options and they've decided to do reverse. I mean, I did one two weeks ago and a 41-year-old, very similar story. I have another patient of similar age where we did, I don't usually do SCRs. Instead, what I would do is a patch in a position where we would tie the patch to what remains of the cuff medially. Because I think if you, while you look at the coronals and you don't see a lot of, I'm sorry, if you look at the sagittal, you don't see a lot of muscle. If you look at the coronals, there is some cuff muscle remaining and my hope would be that if I can get the patch to heal to the muscle and then to the bone, that there might be some strength restoration with that, whereas obviously there's gonna be none of that with an SCR. It's also technically easier and it's cheaper. So there's additional benefits of doing a patch in position instead of an SCR. So those are the two options I would offer the patient. And what do you tell them in terms of expected pain and function after these two options? I would say that with the reverse, that for sure she will be able to elevate her arm again and the pain relief will be good. And I don't know how long it will last. And with the patch in her position, it's questionable whether she'll be able to raise her arm. Generally, the pain relief early on is good, but that the failure rate is higher and the recovery time is substantially longer. So for someone who's 38 folding laundry, she may be caring for small children. She may still have a lot of work to do to maintain her home and her family. And so that sometimes you tell patients, I'm not gonna let you push or pull for four months. And they're like, I don't think I'm gonna do that, doc. Especially when I've been through three prior surgeries that didn't work. So I think that you're hitting on all the points that I do, which is that the reverse is gonna be your more reliable pain relief option. It's going to be an easier recovery on average. There's variability, of course, and better chance that you'll be able to elevate your arm, a substantially better chance. But you're young and long-term longevity is a big concern. So there's one other thing I'm doing in this patient, and again, I don't have a lot of evidence to back this up, but I think it's something that we should be thinking about, which is this patient's 38 years old and she has this cuff, she's had a cuff tear that's developed much earlier than normal. You know, and now she's had- Both shoulders, she's had cuff problems. Okay, so that's what I was gonna get to, so if she hasn't had problems with the other side, then I actually usually get a battery of labs to look at the usual things you would look at with non-unions. You know, when someone comes in with a non-union, we start to think about, is there something physiologically going that's preventing the bone from healing? So I think we should be thinking the same way about the tendon. If you have a tendon that's not healed multiple times, what is the physiological problem? What is the problem with this patient's biology? Because some of those things are fixable, like you may get labs and find this patient has abnormalities with their lipids, abnormalities with their vitamin levels, The other thing you should definitely need to think about is infection in this patient. Is there some sort of chronic P. acnes infection that's been a problem? There, when people have looked at that prospectively and taking cultures from their failed cuffs, it's dramatically high how many of them have positive cultures. If you're gonna do an orthoplasty in this patient, that's very relevant. All right, so all good stuff. She was a smoker, which isn't helping her tissues to heal, but didn't really wanna quit. In this case, we talked about those options and she elected to undergo arthroscopic. Nothing was repairable, unfortunately, and so, as mentioned, I went ahead with the SCR. Many ways to do this, we won't belabor it given the time, but placing anchors, getting set up, measuring, preparing your graft, having a good assistant because there's a lot of sutures and if you get them tangled, it is a big pain. If you keep them untangled, this is not terribly difficult to do with the right help. So shuttling in, this is what it looks like in the end. This is before tying the, I tried to tie the upper subscap over to the graft as well to try to close that anterior, interlateral rotator interval there, but graft looks good and one interesting thing in this patient is that her other shoulder had an SCR and she had a reverse, so I actually did a reverse on this side, but I do think that SCR and reverse or other interposition would be relevant, but given her experience with the SCR that had failed, multiple rotator cuffs, despite her age, she was interested in having bilateral reverse and we'll see how that plays out 10, 20 years down the road, hopefully. But this is a humeral failure of the SCR graft on the left and depending on the study, humeral might be a more common failure site, but certainly it's a challenging topic and a little bit of discussion of SCR, but I think we can move on to the instability cases given the time. So final thoughts, guys? Looks great. That was the right move. Yeah.

physician

irreparable rotator cuff tears

tendon transfer

shoulder pain

function restoration

MRI