I appreciate it. So we're going to go over kind of my approach to these patients, kind of younger patients with that kind of sub-acute chronic massive rotator cuff tear. It can be traumatic or atraumatic, but the majority of times young patients are more traumatic injuries. So this is the type of patient we're looking at. So someone under the age of, I'm 57, so anything that's under 57 is a young patient. So we'll go under the age of 57. Definition of young goes up every year at my birthday. So 57-year-old patient, this is kind of what we see here. I see that the subscapularis tendon is intact, and that's key for the procedures I'm going to talk about is having an intact or repairable subscapularis tendon. So my approach is either rotator cuff repair, either doing a partial full repair, hopefully using their own tissue with the backup of an SCR. So this is my case here. This is actually a 58-year-old, one of my former fellow residents, he's an orthopedic surgeon. He dislocated his left shoulder while being surprised by a baboon in an African safari, so you really can't make this up. But he spooked the baboon, the baboon spooked him. He fell and dislocated his shoulder. He was able to self-reduce it, but three months came out, three months out, still limited active forward elevation. So he could get his arm up at about 140, but significant weakness with abduction and extramutation string testing, and his liftoff testing is intact. By the way, that's a picture of an elephant scapula that he found there. So anyhow, this is his plane radiographs here. You see no significant arthropathy, superior migration. You can see the massive tear kind of retracted back. So some tissue posteriorly still intact, but then you see his subscapularis tendon is still intact anteriorly. So we have a subacute chronic large supraspinatus infraspinatus tendon tear with traction to the glenoid glenohumeral joint level and intact subscapularis tendon and only mild atrophy. So my goal here is you want to try to do a primary repair if you can with SCR as a possible backup. So I think it's important when doing these tears, obviously you want to assess the whole situation here. So you can see there's his supra retracted and there's infraspinatus, and these can scar in pretty quickly. When they have an acute traumatic dislocation, there's a lot of bleeding and stuff, so these tendons tend to scar in pretty quickly. And so we assess the mobility of the tendon here. So you can see we kind of did a little bit of a release. We got it partially open, but still pretty tight. And when you repair these, obviously you want to do a tension-free, as much tension-free possible repair as possible, otherwise they're going to fail. So you really want to assess the mobility and do your releases. Now another situation we see in these young patients is, sorry, when they have an acute episode, they actually get a lot of bleeding in there, and that cuff can actually scar to the underneath surface of the acromion. You get in there and you see this, I don't know if you've seen that before, it's like a big scar tissue, and the body's trying to kind of heal that tendon back and it actually scars the acromion. So the first thing you do is you want to obviously release that. And sometimes it's difficult to find where that edge of the tendon is, but you want to release all that scar tissue and free it up from the acromion. And then you look above. And I like to look from lateral too to fully assess the tendon. Then we do our releases, do a versal side of releases. We go anteriorly first. I'll release the anterior interval often. That helps with mobility as well. I like to kind of pull traction on the tendon as I do this so we can assess the mobility as we release. Then we go posteriorly here. And it's important posteriorly, especially with these larger tears, you want to get a lot of that bursa out of the way. Because when you start passing your sutures and you don't really clear that out posteriorly, you can lose those sutures and it gets very frustrating. And also you want to help with mobility of the tendon as well. So I'm pulling the infraspinatus tendon and then I'm releasing all that kind of bursal sided scar tissue there. The other thing you want to do is it's important to, these tendons are often, tears are delaminated so you have that capsular layer inferiorly here that's really scarred in and you have your bursal layer. So you really need to free that up. And I like to use a blunt probe or anything and I kind of pie crest underneath that capsular layer and kind of release it from the labrum and the glenoid where it's scarred down. I don't like to use a shaver or a burner because that suprascapular nerve is pretty close to the edge of the glenoid and you start buzzing back there. You don't want to injure that. Then we burr down the bone. We just want to get a bleeding bed. You more want to do an abrasion here, I think, especially younger patients have good bone. These older patients, you start doing a burr and you get into, you lose that bone quality, which obviously will affect your anchor place or fixation here. So generally with these large tears, I often use two anchors above at the supraspinatus tendon insertion and we do one posteriorly. So we do one just posterior to the bicipital groove here. And I used to use a combination. They're all suture anchors, but one is tie and one is locked in there. So we'll tie three medial and then the other ones will just be locked into the anchor and we'll do our transosseous equivalent. So these are passing anchors here. It's important when you pass sutures for these large tears with this delaminated portion, you want to get that capsular layer here. You don't want to just go through the bursal layer because this is obviously going to be that superior capsule. That's going to help prevent superior migration. So you really want to make sure you get that. Sometimes I'll use a grasper and pull that area out when we pass our suture. And another here, another more anterior. These apart a centimeter, two centimeters out. And again, when you go through that bursal layer, you want to pull it up. And I used to like to use suture passers because you can really make sure you get that underneath surface because if you miss that capsular layer, that's a big part of the repair. And when I tie our sutures here, I always pull the sutures through a cannula laterally. I want to reduce the tendon so when you're tying, you're not trying to reduce it at the same time. So we'll hold the tendon reduced and then we'll tie our knots and I'll put three medially just to set the tendon where I want it to be. I think I like to do that rather than all transosseous because you don't want to rely on your reduction when you're putting your swivel lock anchor in laterally. You want to have it provisionally reduced so you know where it's going to sit before you put your lateral anchors in. And then we'll do our lateral row here. I use swivel locks here. So I'll usually use two. I always like to burr down that bone there because you want to make sure that you have good visualization with the swivel locks so you don't lose that hole, especially if there's a lot of bursa there. So we'll tap in our anterior anchor. In terms of putting anterior posterior anchor in first, it kind of is the configuration of the tear. If you have those tears that are kind of retracted, kind of anterior medial, you want to maybe do the posterior one first to pull the tendon back. These posterior lateral ones, you want to do the anterior anchor because you want to pull the tendon kind of anterior lateral to get the anatomic reduction of it. Then we'll do our posterior anchor here. Kind of space the anchors out so you get a good spread of the sutures. A lot of times when tapping laterally, I'll use a smaller awl because that lateral cortex or that lateral bone is not as substantial often as that medial bone. So I'll use a little smaller awl there. And we'll screw in our posterior anchor here. And it's important when you screw in that anchor, you want to let go of the tension on the sutures. I think we try to over-tension those sometimes. That over-tension's the repair. But also if there's too much tension on the sutures, it starts caving in that cortex above the anchor. So you want to make sure you kind of let tension go as you, and this is our final construct here. So how do these patients do, these young patients? This is a systematic view looking at patients under the age of 40. And a majority, it's a little bit different animal than these chronic tears in older patients. Generally these are more traumatic type tears and they tend to be acute. There's a subgroup of elite throwers that have these partial thickness tears, but that's kind of a different animal there. That's more of a wear and tear and different group. But these people did well. Rare to the cuff, improved pain and strength, 87% of patients are satisfied overall in this systematic view, except for those elite throwers. As we know, pretty much everything you do from a surgical standpoint is very difficult for them to get back. So what about these repairs in under the age of 60 versus over the age of 60? This study looked at a group of patients of 48. They looked at studies of sequential outcomes. And there was really no difference in postoperative clinical scores or passive range of motion. And the young patients actually complained of less pain than the older patients, which I find it's kind of not intuitive. You think some of these younger patients are going to go back to stressing their shoulder a little bit more so they may have a little bit more pain, but they actually had less pain. And the elderly patients not surprisingly had more advanced fatty infiltration preoperatively than the young patients. And this actually correlated with postoperative integrity. So the re-tear rate is actually much lower even with these larger tears in the young group, 12.5% versus 33% in these older groups. So if I get in there now and the tendon quality is not great, my backup is an SCR. In this case, he had upper border subscut tear. So we repaired that, similar technique as Dr. Verma talked about. And then this is a revision repair. So you can see that tendon quality isn't great. You can still see some of the suture in there. So I think trying to get that to re-heal I think is going to be a futile endeavor. So we in this case go to an SCR. So when I do an SCR, I like to really clear out that tendon. The tendon, some people try to preserve it to augment the repair. But I clear it out because you want to have good visualization of that glenoid for putting your anchors there. And I put two, sometimes three anchors. I've got more than three anchors now. It's important to space them apart. I think the good landmark is the base of the coracoid process for the anterior anchor and the base of the scapular spine for the posterior anchor. You want to make sure you get those anchors medial enough so you're not coming out into the face of the glenoid. And then we put two lateral anchors here. And this is the anchors we use, or the sutures to shuttle the tendon in. We dock the tendon there. And once we dock the tendon, we always look intra-articular because you want to make sure that tendon, or the graft rather, not tendon, is nicely approximated to that superior glenoid. And then once you do that, we tie our medial knots and we put our lateral row in. And then in terms of what to do posteriorly, I pull the infraspinatus tendon and we use one of the sutures from the lateral anchors to pull it out laterally and then we do a side-to-side repair between the back part of the posterior aspect of the graft and the infraspinatus tendon. We close that interval down for a final construct here. Post-operative rehab, it's very important I think with these SCRs or any type of massive tears obviously to really slow down the rehab process. And we don't do much for the first six weeks except for some hand rests and elbows. As Dr. Verma said, a stiff heel tendon is much better than a failed tendon with a full range of motion. And the problem sometimes with these SCR patients is you're not putting much tension on the repair so their pain level is actually a lot lower than a big massive rotator cuff repair and they want to kind of move their shoulder a lot more than you want them to so you've got to be real careful. In terms of results of these, Dr. Miyata, obviously Professor Miyata we talked about earlier, he's kind of brought this to the forefront. He's shown, he uses a tensor fascia autograft and has reported very good results. The first 30 shoulders, five-year results, really only three patients failed with good outcomes. He also has shown in his studies that we haven't been able to recreate over here with our dermal autograft. He can reverse that pseudoparalysis. Again we talked about it, the definition of pseudoparalysis is all over there. But severe pseudoparalysis is that patient that can't raise above 30 degrees and he actually demonstrated he's able to reverse that in 93% of the cases. Additionally we've used the dermal autograft here and we haven't been able to recreate his results. Dr. Warren has shown a 65% failure rate. He looked at several reasons why we have a higher failure rate with the dermal autograft. One is obviously it's an autograft and autograft generally heals better. Graft thickness is probably a big portion of this. These dermal autografts we get are anywhere from three millimeters of thickness to low versus the eight millimeters that he gets with his tensor fascia autografts. That's a big part of it. In a cadaver model he demonstrated that these eight millimeter grafts reduce the subacromial P-contact pressures and reduce superior translation much more than the four millimeter grafts. So again, thickness really makes a huge difference. Denard showed a little bit better results, 75% success rates. But again, low healing, 45% healing rate on postoperative MRI scans. And again, they demonstrated graft thickness played a huge role in the Hamada classification as Dr. Berman talked about. So does that dermal autograft actually heal? Well, we actually had a case where a patient was a year out from a SCR reconstruction with dermal autograft, had an injury where he fell and fell to his shoulder, dislocate, self-reduced, came in very guarded to the office, so we're actually able to image his shoulder then. And you can see here, subscap is still intact, but he had kind of a haggle lesion here, a big haggle lesion, see the big effusion here. But look at the graft. You can see here the graft is still intact. Then look in the sagittal views, you can see the infraspinatus actually still healed back to the posterior aspect of the graft. We don't close the anterior intervals, so you're always going to see fluid there. So we're able to re-scope the shoulder. There's his haggle lesion. Now we're in intra-articular here, and you can see there's the graft still healed down to the glenoid. And then laterally at the goiter tuberosity insertion, you actually see vascularity of the graft on the articular side. And then we go up on the bursal side, and again you see vascularity. That's the graft there that's incorporated into the bone. And actually the infraspinatus tendon is still nicely healed back to the posterior aspect of the graft. And this study actually looked at this. They had a longitudinal evaluation and demonstrated there was healing both medially and laterally. And they did biopsies. We probably should have done a biopsy. We didn't think about it at the time, but it would have been interesting to see. But there was revascularization, particularly at that lateral aspect of the graft with a high repopulation of host cells. So the body does incorporate that graft, it seems. This is, again, that study showing that that's the graft at two weeks, six months, one year, and two years. So it tends to kind of maintain over time. So in conclusion, SER can help this difficult population if it's an irreparable tear. I think we still need to further refine the indications. Also we need to refine our techniques. You know, do we use dermal allograft, tensor fascia allograft seem to do better? Do we close that poster interval? Do we close that anterior interval? Those are all things I think we need to work out. So I appreciate it and thank you.

younger patients

sub-acute chronic massive rotator cuff tears

subscapularis tendon

rotator cuff repair

surgical technique