We understand the natural history of many of these conditions. We all know that many of these patients exist for long periods of time in an asymptomatic state and then something triggers and they become symptomatic. What we really want to understand from them is two things. Number one, what is their symptomatology? Is it a pain issue? Is it a functional issue? Or is it both? And what has been the progression of their disease? Is this, I was normal and I just fell over my dog and now I can't lift my arm? Or I started playing more tennis about a month ago and all of a sudden my shoulder is hurting me more. And these things can help you to decide how aggressive you need to be in a surgical situation versus the utility of a trial of non-operative care. What we really don't understand and what makes these tears really hard to manage is why do they hurt and why do they cause functional loss? Because we all have seen patients with these larger massive tears, incidentally seen on imaging. They come in and they do this and they say my shoulder is perfectly fine. And then we see others that have small tears. They come in and they do this and they say I can't sleep at night and this is miserably painful. So why do some of these tears hurt? I think this is important in deciding how do we address these, particularly in a surgical setting. It can be bursal inflammation, synovitis, other inter-articular pathology, subacromial pathology. And I think the more and more we learn about this, it's really the impingement between the humeral head or the tuberosity and the acromion that may be a big driver of pain for many of these patients. In terms of functional loss, well by and away the most common reason why people lose function is because it hurts. And if we take away their pain, their function improves. But we do know that there are these situations where they have loss of compensatory muscle strength, where they have a loss of a neurologic initiation or sequencing of the way that the muscles activate to allow them to elevate. We know it can be based on the location, not necessarily the size of the tear, particularly with subscapularis involvement. And certainly if we lose that force couple between the front and the back of the rotator cuff so they can no longer depress the humeral head, this can result in loss of arm elevation. So the next thing we want to do is to ask the patient really, what is it that you want? What are your priorities with regard to how we're going to manage this condition? And some of the hardest things are these younger patients that come in with these massive tears and atrophy, and they want their strength back. And we may not have an operation that's going to do that for them. What we do know is that if the older patients come in, they more often prioritize pain relief. Younger patients will more often trade a little bit of residual pain for strength recovery. But I think identifying what the patient wants and making sure you have a rational discussion with them about what your procedure can achieve is extremely important. We all think about these concepts of humeral head depression, concavity compression, deltoid innovation, elevation, and then ultimately pain relief. And we think this is how many of the procedures that we perform work. But the reality is what the patient is looking for is they want, number one, to sleep at night and they want, number two, to be able to function better so that they can get their arm overhead and do the things that they want to do. Unfortunately, we also know that there's a disconnect between the outcomes following rotator cuff surgery and the structural integrity of the repair. The general rotator cuff outcomes, 85 to 90% good results across the board, even in large to massive cases with high levels of patient satisfaction. But if we look at are we actually getting the tendon to heal, we're not doing quite as well as we think. With small tears, somewhere between 10% and 25% recurrence, and as we get into these larger tears, 50% or more may be structurally non-intact at the time of six-month or one-year follow-up. Fortunately, they do well. But the one area where we do see that they have problems is strength recovery. So that's the one that's the hardest to achieve following these types of procedures. When we follow these patients who have failed structural integrity of their rotator cuff, so we looked at a group of patients initially. We found the group that was clinically asymptomatic but had an incidental finding of a structurally deficient rotator cuff on MRI. And we followed them for seven years. And we found that there was a very low risk of revision surgery. Tears got bigger. Strength started to deteriorate. But none of the patients in our group actually required revision. So even when they fail, they can do well for long periods of time. The next thing I want to look at is what is their physical exam? And for me, the key metric here is can they get their arm above shoulder level or not? If they can elevate their arm above shoulder level, you've got lots of options on the table. If they can't elevate their arm above shoulder level, then you've got to decide, is that a pain-mediated issue or is it true pseudoparalysis? If it's a pain-mediated issue, again, we probably have some good options that can help them. If it's true pseudoparalysis and we can talk about what the definition of that is, I think that we're much more limited in our ability to reverse that. And of course, there's a lot of literature that would discuss that finding. We do want to make sure that when we examine them that we evaluate for alternate sources of pain, which oftentimes if you correct these, that's 75% or 80% of the battle. This is things like AC joint, biceps pathology or stiffness. We need to make sure that we're addressing all of the pain generators in the shoulder and not just simply focusing on the rotator cuff itself. And there's some good literature that may suggest that even if we just debride, that we may achieve good results with regard to pain relief and clinical outcomes. This problem with pseudoparalysis is that the definitions are all over the board, right? If you look in the literature in terms of reversing pseudoparalysis at the very basics, many people define that as lack of elevation over 90 degrees. But we all know that there's a very different presentation between the person that comes in three or four months after an acute trauma, they've got a small supraspinatus tear and they get to here, but with one finger they get to here, versus the patient that comes in that looks like this, where they literally have complete absence of glenohumeral elevation. They've got anterior superior escape on the x-ray and they've got a massive tear that involves the supraspinatus and the subscapularis as well as the infraspinatus with muscle atrophy. Those are two very different animals, but both of them have elevation less than 90 degrees. So unfortunately we've got to be a little bit more critical with our definition. And the reality for me is I know it when I see it. My definition is they have to be a chronic tear, so generally these are patients that have had rotator cuff pathology for at least six months, in many cases a year or more. They've got to have a massive tear that involves the subscapularis and they've got to have complete loss of active elevation at the glenohumeral joint. And generally they're painless. So these are patients that come in and the only motion they have is with the shoulder shrug. They're getting no active elevation at the glenohumeral joint. We've looked at this to try to determine can we agree on at least a criteria for what determines pseudoparalysis, or can we all look at the same patients and say that they're pseudoparalytic. And as you would expect, there's really wide disagreement in terms of both. How do we diagnose it? How do we define it? And then how do we determine if it's present in a given patient? But I think for many of us we identify when we can see a patient with pseudoparalysis and whether it's true pseudoparalysis or actually pain mediated. The clinical outcomes, again, there is literature out there that suggests that we can reverse this, but I think one man's pseudoparalysis is probably another man or woman's pseudoparesis. So we've got to be careful about the definition. Radiographs have become very helpful in my practice. We used to get them just as a kind of a rule out procedure, but what I find is the homotic classification is extremely helpful. Again, if you've got somebody that's hemato one or two, which means the glenohumeral joint is centered or about less than a centimeter of elevation without contact with the above acromion, you're in the game in terms of soft tissue procedures. As soon as you start to see contact between the humeral head and the acromion, or certainly as soon as you start to see osteoarthritis or post-traumatic or post-rotator cuff arthropathy in the glenohumeral joint, we really need to start thinking about alternate procedures, especially in the older patients, such as reverse arthroplasty, which I know is a bad word in the sports medicine setting, but works extremely well, and the rates of complications are no longer that 10, 15, 20% that we used to talk about. They're now in the 1% to 2% range with a much quicker recovery. So look closely at your x-rays to determine candidacy for soft tissue procedures versus other. The MRI findings, I think, are helpful. We all know how to define these massive rotator cuff tears, but really we have to be a little bit more nuanced as how we look at these. What I want to know is what's the tear pattern, what's the tendon quality, and what's the muscle quality? If I've got good tendon and I've got muscle that's alive, I've got the ability to perform some type of a reparative procedure and generally achieve a good result. We know that these muscle changes occur in a predictable pattern, and they do take on average a year to 18 months before they start to develop. So they give you some form of prediction of the chronicity of the tear. And then all of the tear patterns that we're familiar with in terms of crescentaric L or reverse L tears, the U-shaped tears, and finally making sure we're looking at the subscapularis. We do know that these MRIs have been helpful in determining the recurrence rates following surgery and this is structural failure. The more guttale atrophy and fatty infiltration that you have, the more likely it is that your rotator cuff will fail to heal. But again, we have to be careful about equating healing with a good functional or pain relief outcome for our patients. We know that the tendon tends to deteriorate over time. But again, even when you see these high degrees of fatty infiltration and or atrophy, we can still achieve a reasonable clinical result for our patients. Don't forget about the subscapularis and the biceps. The subscapularis is critical, particularly in reestablishing your force couple. And at times you can see these upper border subscapularis tears where there's really delamination. Unless you look closely you're going to miss them. I think the subscapularis is critical for reestablishing the normal force couple to allow elevation. Here's just a couple of examples of these subtle upper border tears as well as these full thickness larger size tears. And this is an example of that upper border tear that I think you can miss. As you look at it from the side and we start to pull away, you see that there's just that delamination of the upper border of the subscapularis and we want to reestablish that to bring the force couple above the equator. Well how do we do that? I think with some of our newer products that are on the market it's become easier and easier for us to do. My preference is to do this while looking from the lateral portal, not an interarticular. I get this direct view. I essentially place one of the knotless all suture anchors. You can use a direct penetration with your anchor guide through the inferior aspect of the subscapularis and then shuttle the additional stitch, the same stitch back through in a mattress configuration, deploy it in the anchor and you create a suture staple which is just a quick easy way to deal with these upper border type tears. The technique, I know that other people are going to talk about this. This is kind of my algorithm for how to manage these patients. Smaller tears are a double row with one medial and two lateral. As we get to larger tears I start to do a double row for the supraspinatus adding a single anchor for the infraspinatus and then finally for these massive cuffs I prefer a single row low tension repair over a double row high tension repair medializing the footprint on the greater tuberosity as necessary and triple loaded anchors to allow multiple points of fixation. So here's what that looks like on the top left is that small one in one I call it. So it's a less than 1.5 centimeter tear. You place a medial anchor, pass the sutures in a mattress configuration. This is a very low tension repair construct. So you can choose to tie knots or avoid tying knots. In many of these situations I no longer tie knots. As we get bigger we'll put a single anchor at the junction of the supraspinatus which is defined by the margin of the bare area. We'll pass simple sutures through the infraspinatus and then double row in whichever fashion you choose to do that for the supraspinatus. And then finally the single row medialized repairs with triple loaded anchors in the larger situation. And I think some of the other speakers will get into that. We do know that there's good data on using these triple loaded single row anchors. We can actually reestablish the footprint simply by the healing process that occurs. When we think about the technique steps, I think viewing from the lateral portal is really important so that you can understand the architecture and the configuration of your tear. We need to mobilize, be comfortable doing the releases both in the anchor and poster aspect. Take care of the biceps. This is often involved in these procedures. Do whatever else you need to do with decompressions and distal clavicles. Prepare the bone appropriately. And then finally an anatomic repair here is critical for low tension. What's the role of an acromioplasty? Well our data would suggest that there's a minimal role for acromioplasty at least in regards to patient outcomes. Remember these are small numbers of type 3 acromions so it's very hard to generalize this. It doesn't look at structural healing. I do think that there's a value similar to a noshplasty in an ACL situation. But we do know at the long term that if you apply acromioplasty to all comers there's no difference in outcomes. I don't think we throw the entire procedure out and there's value still for the surgeon in visualization. What we do know is that there's very limited complications associated with acromioplasty. So if you think they need it or you think you need it to be able to see, don't worry about doing it. Finally augmentation, there's a lot of different things out there that we can augment with. One of the things that we're looking at in practice will be the next big front in rotator cuff surgery is trying to improve biology. The questions that we have are what do we use, when do we use it and how do we deliver it? And these remain questions and answers. We know that things like DBM as well as PRP do have multiple studies that suggest that in these larger tears we may be able to improve outcomes. We've looked at BMAC as well as the French and the Korean and have demonstrated that we do see better improvement of the appearance of the healing on MRI scan although clinical outcomes are not different. Obviously this is a very easy augment to do and we simply inject it at the end of the procedure and we've demonstrated that our revision rates and our retear rates are lower after doing that. What about these extracellular matrix augmentations? Well they provide potentially a biomechanical augmentation as well as a biologic augmentation with the goal of trying to improve our time equals zero repair mechanics but also improving our outcomes in regards to healing of the tendon by providing collagen for support and native tendon remodeling with a more anatomic reconstruction. How do we decide when to do this? We know that at least from a systematic review standpoint that there is data that would suggest that adding these augments do help. I think that this Rohy scale is very helpful in deciding how to manage these patients. This is similar to the French scale that we use, the ISIS scale for instability, just looking at all of the patient-related factors that may predict a failure after surgery and then algorithmically applying when do we decide that a patch may be necessary. The good news is that these patches are becoming easier and easier to deploy. There's a lot of commercially available patch kits that are now present on the market. For me this is a Rohy score of at least 7 in repairable tears and my preference is a dermal allograft because of both the biomechanical as well as the biologic properties. And the techniques for this are available. This is one of our techniques for performing a patch augmentation. And on the right is just a new bioinductive implant where you actually place a DBM top hat under the repair site. So I think that's one of the debates that we need to kind of solve is, should we be using tissue over the top or should we be using something at the interface to actually promote biologic healing and thesis regeneration? Finally rehabilitation, my discussion here is really just go slow when you need to go slow and customize for each patient. My preference is always to deal with a stiff patient that has a healed rotator cuff rather than a patient that has a recurrent rotator cuff deficiency. So go slow when necessary, sling immobilization for six, sometimes even up to eight weeks for some of these more complex procedures. And then finally, don't forget about the balloon. It can be a very valuable adjunct for you in managing these patients, particularly older patients who prioritize pain over function. They have maintained ability to elevate their arm and minimal arthritis. In our series as well as others around the literature, I think you heard from Buddy yesterday and maybe later today about how we can even use this as an augment to a repair. But I think this is becoming a valuable product for us in managing these patients. Thanks very much for your attention.

rotator cuff tears

treatment

symptomatology

diagnosis

rehabilitation programs