some slight discrepancies on his subscap. He has positive provocative O'Briens, Nears, and Hawkins. You can see that little hitch in his motion there. Well-controlled diabetic, otherwise high blood pressure, no other comorbidities, which I think it's important. In terms of the imaging, you can see a slight down-sloping type two acromion for whatever that means to you. You can see some reactive changes within the tuberosity, no de-centering on those axillary image. And then coronal sequences show a retracted tear. You can see this is in the supine position, so it's important to reconcile that AP with what you see here, which shows what appears to be narrowing of that subacromial space, but it just implies retraction, and that they are axially unstable. You also will look at the sagittal views. That helps to get an appreciation, at least for the level of atrophy. You can see, in this case, with medialization of that muscle belly and some slight fatty infiltration, both in the supraspinatus and infraspinatus. And then the axial images, to the conversation we were just having, scrutinizing for that subscapularis pathology, as is shown here, and you can see retraction with structural changes within the biceps tendon. So the big question is how you manage this, and sometimes we talk about this from the podium and how we approach it in our operating rooms can be quite different. So I'm gonna work through a little bit of what that looks like for me, and I would say there's no one technique for approaching these types of pathology, but to the conversation that we were just having with subluxation of the biceps, you can see with that poster lever push, it's really excellent for being able to create some daylight between the subscapularis and the humeral head to allow you to see the presence of that potentially hidden subscapularis lesion. You can see there's structural damage there, and obviously subluxation. So approaching this, I think when you do this, this is a beach chair position, posterior viewing, I think you need to remove the biceps. You can tag it, certainly use that for spare parts at a later stage in the procedure if that's your decision, but I think that's gonna make it infinitely easier for you to address this subscapularis pathology. For me, it's doing a three-sided release, so you wanna make sure, as Sarah mentioned, you wanna really scarify the coracoid so you can identify where that is. Release all three margins, including the MGHL and IGHL. I think that just allows you an unfettered approach to repair, and then ultimately preparing the tuberosity. My preference generally is to get a good traction suture, and so it's to use these looped sutures in order to allow me to do a trial reduction. And that's through an ancillary portal. It's doing this coracohumeral release, this interval release in continuity, viewing medially to make sure that you have full excursion of that subscapularis so that you can achieve repair. You can do a medialization of that lesser tuberosity. I think that number's a little less clear than the supraspinatus, but it has been suggested that five to 10 millimeters may be acceptable. And I like to preserve that laterally-based comma tissue because I think that, one, helps with the reduction of your supraspinatus, also helps the load share at later stages in the procedure. The order or sequence of events is doing the subscapularis, proceeding to restoring that force couple, so that infraspinatus, and then, really, that makes a very concrete, often crescent or U-shaped tear that you can later address with the supraspinatus. Here's just a sequence of events here. You can see with our traction sutures, I like these loop sutures, often tape-based construct, so you can really gain control. And then I do more of an onlay approach, especially when it's these top half tears of the subscapularis. Many of these anchors now have an additional mechanism built into it where you can use a knotless reinforcement of that top border to really restore that quite nicely. Again, tear pattern recognition, that can't be under-emphasized. You can see these U or L or reverse L-shaped tears can often show up in very similar type of context, so you want to make sure you're doing a trial reduction just as if you're doing fracture surgery, and I think that's been very helpful when viewing through the lateral portal. The subacromial eval, as was alluded to, is really key. I do like to still do a subacromial decompression. I think that's valuable for creating a larger working space additionally to recruit bioactive factors, and if it is prominent laterally, it may decrease abrasion on our repair construct. I think the important discussion point here is to make sure that when you're preparing the tuberosity, you get down, you strip down the soft tissue, you can see the footprint appropriately, and then just to score the bone just slightly with a shaver, not with a burr often for me, in order to make sure you're recruiting those bioactive factors and enhancing healing. You can see oftentimes we're using these cuff graspers, which I think is less likely to pinch or pull through that tissue. In this case, this is an L-shaped pattern, and we're just really making sure that we restore those delaminated portions and getting that out to length. So margin convergence is very helpful. Again, this helps to just make your procedure earlier as you go along, and what you're trying to do is ensure that you have decreased surface area required for healing. So you're bringing these two together. It's gonna be low chairing in nature. Address those lamina. You can do that with either a suture hook type of device or some of these retrograde passers that are very helpful for restoring native anatomy. And then really, you can choose one of two ways. You can do it with an anchor-based margin convergence, which I think is nice as you approach laterally, or you can potentially do it with free sutures and what was described as the suture hook technique or utilizing it via anchor. So this is the final tendon construct. We've repaired the infraspinatus after the subscapularis. We've achieved apposition. We've used these little small luggage tag stitches to address our dog ear, and you can see the final construct shows good stability despite poor quality tissue delamination and some element of fatty atrophy. I think the discussion points that we could implement in our tables is what constitutes irreparable and when do we start to think about augmentation? How does this diagnosis of pseudoparalysis play into our overall discussion, both in the office and the OR? I think these are some of the variables that we should consider when individualizing our repair constructs. Ultimately, those margin convergence sutures have many different biomechanical advantages, and those are shown here. These load sharing ripstop type of configurations as described by Steve Burkhart, very, very helpful to make sure you don't have suture pull through, which can create radial tears, and I think that's potentially a source of failure that we see in some of our patients and maybe preventing us from earlier, more aggressive rehabilitation. So these self-grasping suture configurations, I definitely would like to have the group discuss. With that, I think I'll pass it off to Nick Verma, who will have slick slides, better surgical technique, and we'll bring it home. Thanks. Thank you.

shoulder injury

surgical approach

tear pattern recognition

infraspinatus repair

Nick Verma