table. So one quick plug for margin convergence. I'm a big believer in these massive tears. If you look laterally and you use your grasper to pull the different leafs, both medial to lateral, anterior to posterior, you can, just like a fracture, figure out how to put it back together. And when we can margin convergence, it works really well. So we have a couple cases to show. We're gonna get our experts' thoughts on them, and then we'll have some time for some questions as well. So this first case is a 62-year-old active male. You can see some MRI cuts in his x-ray. We have some video here of his MRI. He's got a large supraspinatus tear. He's got a subscapularis tear. So this video's not playing here. Well, video's not playing, but his subscapularis was fixed, and you see he's got a very mobile but massive supra and infraterior. I assume everyone up here on the panel is gonna try to fix this. How would you fix this, Gus? What would be your technique? Oh, I would just do a double-row transosseous equivalent, you know, just kind of doing what we had already spoken about. Make sure it's tension-free repair if you had to. I don't really medialize a lot, but I know some people do. And then, yeah, that's it. Any thoughts, Buddy or Grant, on how you'd fix this? Yeah, I like fixing the subscap first, as you did. And sometimes I'll actually move it up a little bit. I learned that from Bob Kofio. He used to call it a subcap slide, where he would move it up a little bit higher on a massive tear to kind of close that gap, give you a better triangle. And then it's hard to see how far down it goes, but if it goes all the way down to the infraspinatus, the lower part of the infraspinatus, or upper teres minor, then I would put two medial anchors, both triple-loaded, one for supraspinatus and upper infraspinatus, and the second one for infraspinatus and teres minor, and then a lateral row anchor to put it back. And I would add a patch to this one. I think your tendon looks a little ragged. It's thick, but it looks ragged. But unless it lays down really nicely and looks better than it looks on that edge, I'd probably add a patch. How about you, Grant? Would you add anything? So pretty much the same, transosseous equivalent. I used to tie a lot of medial row. I'd put three anchors in and tie six sutures, but I think you're probably strangulating the cuff there, and I think you're setting yourself up for a medial failure or a type 2 failure. So I will tie just, as I said, and it showed in my thing, I'll just tie three. So we'll leave a lot of that medial cuff not compressed, and then we repair with the swivel axillary. So Gus, you have a no atrophy, acute, massive tear that can fix. Are you going to do any biologics or patches to help augment healing in this situation? Yeah, I'm not a big patch guy. We've looked at a bunch. They do a great job of holding on to cells. Oh, thanks. They do a great job of holding on to cells, but so I think acute rotator cuff tear like you have there, you have plenty of bursa, like we'll throw some bursa in. PRP, anything like that for an acute tear? Well, no, not PRP formally. We use PRP, PPP, and then autologous thrombin to make our clot. So that's how we make our fibrin clot. How do you secure your clot? Will you stay in the right spot? No, that's the goofy part of it right now. We've tried a lot of different ways. So we'll try to use a big like jamb sheeting needle and kind of inject it underneath. We try to go through the, you know, fix everything except for the last anchor and then sneak it in underneath that last anchor. But no, that's really, that's the only part of it that's not ready for prime time. Okay, we're going to keep moving here so we have time for questions. Next case is a 52-year-old factory worker, shoulder pain after a work injury. Years ago, he had two previous repairs at an outside institution. You can see his, you know, his head is high-riding. He's got these old metal anchors that I don't like to see usually. Here is, you know, cuts of his MRI, huge tear. You can see anchor tracks, atrophy. The T1 sagittals don't go quite as, you know, medial as we'd like. So here's his, you know, cuts of his MRI. Buddy, what are you thinking here on this guy? I tend to always think fixing. When you look at it, there's a number of things that come up. Achilles superlative migrated on the x-rays. I was really concerned that maybe they had whacked out the greater tuberosity because that's a game changer in a negative way. You still have fluid at your AC joint. That part's sticking down. The atrophy, yeah, so on those, you're like, oh my goodness, this could be a problem. But then when you go back to the MRI scan, at least he has a tuberosity. And I think that was just scattered from the anchors. So I would, on those images to the right, I would classify the supraspinatus as a 5 and the infraspinatus as a 6. So a lower trap would be in the mix for me. But I think in his infracapsule, and I'm going back and forth between images, it's tight. I think that when you look at the nerve, there's scar tissue there medially on the suprascapular notch. So for me, this would be complete release. I think we can get the muscle and tendons back. We talked to him a little bit about lower trap and depend on what kind of factory work he did. If he could stay low, I probably wouldn't do it and just do another repair. But if he had to go up with his arm, especially in here, I think a lower trap might be a good option for him in addition to the repair. And just to reiterate what you said earlier, we have some people in our state doing reverses and some of these young active people that failed two cuffs. And my experience has been they do not do well, especially if they're trying to do any type of manual labor. So this is one, in my mind, that reverse would not be a great option. Would you guys agree with that? Yeah, 100%. I did. I saw that pretty quickly. Any comments, Grant? I think a lower trapezius would be a good option. Try to repair what you can. And then I think that would be a good option. His subscap obviously looks pretty good. So that's one good thing he's got going for him. And as long as his active elevation is preserved. But I think lower trap and whatever type of repair that you can get. So here's a picture showing kind of previous sutures. This is after a little bit of a cleanup. Not the best tissue. In this case, we decided to do an SCR. Again, I think there's a lot of options for these. No perfect option. He ended up doing pretty well, but the thought process would be, you know, young active, trying to give him, you know, more of some active elevation with, you know, activity. What anyone experience with this population? The only thing I just, I do a lot of, we do SCRs a lot of times in these situations. But, you know, and I just kind of worry when I see that superior migration on that, on the plane radiograph side. That's what made me a little hesitant about this. But, you know, I mean, I think it's certainly a reasonable option as well. No, I think that's very true. I do think there's probably a cushion effect of the fibrous tissue between the humeral head and the acromion that functions as a poor man, sometimes, you know, centering it. I know that's not, you know, scientific, but any comments, Gus, on this patient? No. Okay. One more case and then we can open up some questions. 76-year-old active male, plays tennis. His full active abduction. Main complaint is pain. You can see his x-rays here. Very large tear. Previous, you know, surgery in the way distant past. This is axial. So, he came to see me specifically because he wanted nothing to do with the reverse. So, he said, I'm not even going to consider reverse. I get a lot of patients that find me that say reverse is not an option. Do I have any other options? So, go ahead, Gus. So, if he wants to go back to tennis, then you can't serve with a reverse. And if he's a competitive tennis player, he's going to be pissed. They don't want to do this. You know, maybe switch to pickleball, that'd be a different activity, but if they're an avid tennis player, you got to go in the mix of a repair as best you can, do all the stuff with patches and spacers, and you got to tell them it's nine to twelve months, get back. We'll have you on ground strokes early. I have a whole return to tennis program, but key is not let him start getting out there to do overheads until he's ready. But a tennis player that wants to keep playing tennis, then I'm going to fix that cuff and do the best I can with it. If he's willing to switch to golf or something else, or he doesn't mind serving a little bit underhanded or a short ball, but if they're competitive, they're not going to do it. They got it. They want it back. So, just to give you more background, he's okay with giving up the overhand tennis serve. So, he's willing to modify activities in that way, but play underhand. Grant, any thoughts on this one? I mean, it's one I'd, you know, potentially consider, you know, doing repair and maybe even backing up with a balloon to try to keep the, like Buddy talked about, keeping the head down a little bit more and protecting the repair. I think that would be a reasonable option. His joint looks pretty good there, so. So, his cartilage looks pretty nice for considering, you know, his age and his activity. So, this is one where the tissue is just not great. So, even doing some earlier releases, it just was pretty clear this was just not going to come back. So, in this one, we did put a balloon spacer in and he's done pretty well. Clearly, we educate pretty, you know, clearly ahead of time that you're not going to have great strength overhead with this, but from my experience, it works really well for pain. If they have active abduction and no pseudo-paralysis or, you know, limitation of the active overhead motion, this has worked pretty well to give them pain relief and let them be more active. So, let's open it up for questions, if anyone wants to ask. Why don't you head to the microphone right there, if you don't mind. Great talk, guys. The one thing that no one's mentioned really is the concept of a tuberoplasty because the advantage of the lower trap transfer, the advantage of the spacer, to a certain extent, the advantage of the SCR, and we've done probably over 100 SCRs, is that you're creating an interposition in there. So, this last patient that you had, have any of you started to switch a little bit to the tuberoplasty? The patient's got good active motion, it's purely pain, they want to kind of get back quick, they're an active kind of person, understand that their function is probably going to be about the same. How many of you have started down the tuberoplasty road just for the interposition portion? Are you talking about the old tuberoplasty John Finlan did or the new one where you just put the dermis on top? Just put the dermis or double it up and create some form of bumper where you're not going to create a, you know, a huge change in a large hematoma group. You still get that kind of pain relief, theoretically. No, so I haven't done it. I've been looking at it a little bit. It would really depend on, I tend to fix cuffs, and so I may be achieving that unintentionally, and so, but I haven't done it specifically because I usually use the patient's own tissue to cover it rather than adding a dermal patch on top, but I think it's certainly a reasonable thing. Like I said, everything needs to be in your armamentarium, so. Yeah, I don't have any experience with that, but it's certainly something I want to consider or look into in the future. I would say that I came about, just so you know, that what we're talking about is that what they found was that a fair number of SCRs, even though they didn't heal to the glenoid, actually still had pretty good pain relief and function because the graft healed on the greater tuberosity, so some folks have looked at that and said, well, let me just forget the glenoid part of it. I'll put it on the tuberosity, create a space, and keep the head down that way, and then some people are doing it on the acromial side. I think Matt Ravencroft and a couple people are doing it on the other side where they sew it up to the acromion, so I think either way, creating a space that would, something that keeps the head down is probably a good idea, and they don't grind when they go up because you all know massive cuffs that have really good function and then a little bit of pain, so it's not an unreasonable thing, you know, kind of step past the SCR and maybe work just as well. Well, one of the thoughts behind the spacer is you retrain with physical therapy your, you know, your deltoid and your muscles to control the head in space. I would think that would serve the same role, and I do think there's a role for something in that space. I think it's, in my experience, very variable in how they do, though, with outcomes. Any other questions for us? Do you change your treatment algorithm at all? In a situation where you have an elderly female with osteoporosis, does that push you a little bit more towards the arthroplasty decision? Any tips and tricks in those patients that you have to get anchors to stick in that crappy bone? You can use the Zimmer. I don't have any interest in the company. Zimmer is a subchondroplasty system, so when you have those people and you get your x-ray MRI scan and there's this big hole in the greater tuberosity and you know that you're gonna puncture it with a needle and it's nothing, right? So you can take it and we'll start that with a side port cannula, put it in from the side, put the calcium phosphate in there because it takes about 15 to 20 minutes to harden. So while they're doing that, while that little drill guide is still staying in place and that's hardening, we'll go in the shoulder and do our releases. Usually by the time you finish the releases and ready to go in the birth, so you can pull it out. And that thing holds an anchor. I was concerned at the beginning when we started using it that it would impact blood flow into the tendon and impact healing, but it does not seem to. On ultrasound there was no difference and that is rock-solid. And I've actually had some times where they've had a big cyst where you put that in there and the bone actually cracks a little bit because it's expansile, but it still holds the anchor and it doesn't, you know, the whole thing doesn't migrate out. You got to tell your radiologist if you have somebody reading your post-op x-rays because they'll read back that there's a blastic lesion in the greater tuberosity, but otherwise it'll hold an anchor. And I've had a couple situations have been there, you try the anchors. I think a couple steps first, you know, small punches or maybe not punch at all, the bones, you know, just screwing it without doing much or make a little pilot hole so you don't really disturb that. So we try that first, kind of larger anchors. One time I actually got in there and just nothing held. That's a great option, buddy, too, and that would have been one to consider, but I've actually done like a transosseous tunnel. So, you know, it's easy to get where that tuberosity, where that cancellous bone is, the superior aspect of the greater tuberosity, it's easy to get in that. So you just punch a couple holes laterally and bring like a suture passer up through those holes, pass those around. So you're just basically doing it like a mini open or an open transosseous. I've done that a couple of times. That seems to have held alright. Two other hints. One of them I hate to say because on revisions it's our spot, but you can use the proximal part of the bicipital groove. The ridge is actually really good for an anchor to hold bone, and the problem is that that's the spot we use for an anchor when we do a revision cuff. And people have had a lot of anchors in and there's nothing to work with on the back, you can do that. And then lastly, you can take an all suture anchor and punch through the medial calcar of the humerus. So you don't, you always think about this, but you have to have something, you don't want to do a screw-in anchor over there, but you can do some of the all suture anchors and actually drill all the way through, through the medial cortex, seat that anchor on the other side of it, cinch it. Now your stitches are going to migrate through the bone, so you got to kind of watch that a little bit, but that's another spot you can put an anchor. Yeah, question. Great talk, I appreciate all the information you're giving us. Question about decompressions. The guidelines from the Academy, the literature sort of tells us don't do decompressions anymore with cuff repairs. Just curious from the panel, if you are still doing decompressions routinely, either in primary or revision situations? So Moosemeyer's recent article with 10-year follow-up showed that he had a higher re-tear rate after five years in folks he didn't do a decompression on. So now there's evidence that the other way is, at least there's some evidence to support that. The Academy is not going to change the guidelines because it's not coming up again soon, but that's now in there. And it actually, I think it's in the WLA, that article is. If I see anything on the acromion and I'm not doing a spacer, after my horrible experience with that one, which may or may not be applicable to your practice, but if I see anything I'm going to do a decompression. I like to get the view. I think taking one on the cortex gives me better blood supply. I always make sure that it's very smooth. If there's an increased critical shoulder angle on the lateral side, then I'll bevel the lateral sides. I think that does affect tendon healing. So those are my indications, but if you ask me routinely, it's not like 20 years ago where you always did a decompression no matter what as first steps. We don't do that. We really look at it and see what's happening. And if you don't know, if you can't tell preoperatively, when you put the scope in, if you look up at the acromion and there's a lot of fraying, you should do a decompression because it's rubbing on something. And if you don't see fraying, you should leave it alone because it doesn't need to be touched. I think a lot of times I do a decompression because the first thing when you go talk to the family, they ask, did you get that bone spur? You know, they want a big massive repair and all they care about is if you got the bone spur. But no, seriously, I think, as Buddy said, I think I'll do a little bit of an acromioplasty on most of these. I think probably stimulates a little healing, brings some blood flow into that area. I don't get real aggressive, especially in these larger tears because I worry about, I mean, I don't know if the science behind it, but destabilizing the coracochromial arch, I worry about that. So I don't do, you know, just get enough, get it smooth and get some bleeding. Time for one more question. Thank you. I appreciate all the input you guys gave us today. Question, nobody's really addressed the bridging allograft option for larger, massive tears. So Sneed-Snyder's SCOE technique, where you do an interposition between the muscle and the tendon. So I have done that a few times in the past, and now that I've gotten better at releases, I don't think it's necessary. But, you know, everything has a place somewhere, but I just don't, I've not found that it added a lot to my practice. Yeah, I don't have much experience with that, too. I've done it as well, and in my experiences, it's, there's better options. Thanks for coming. Meeting starts in a few minutes, so.

repairing massive rotator cuff tears

techniques for rotator cuff repair

anchors for rotator cuff repair

patches and biologics for rotator cuff repair

subcap slide and tuberoplasty techniques

individualized treatment plans for rotator cuff repair