discussion that we've all been lying about. And the problem is, is we're not defining our terms. If Hawk were here, he'd say, if you're going to talk to me, define your terms. He'd quote Roche Spear. He always does this. And so those of you that know him well would say, look, we're not comparing apples to apples here. And the reason is, is this. You'll notice that with the balloon talk, one of the prerequisites that everybody talks about is you cannot have loss of motion. So we talk about pseudo-paralysis all the time, and I'll give a little bit of detail about that. But the truth is, you have to first decide whether this is a functional cuff or a non-functional cuff. So for example, and I'm going to show you, we'll get going here, and I'll show you a couple of these things with this. I think that the SCR is a game changer, but I'm going to show you this guy. Now, this guy came into my office, and he is a rancher bilaterally. And before I did, at the beginning of it, I said, raise both your arms, and he did this. We called him, well, a pseudo-paralysis, for sure. Well, then we injected both arms, OK, with glycocaine, which we all say we do. But in truth, in 16 studies in the literature, nobody did. So you're not doing it either. Maybe you are sometimes, and I hope you are. Because when you inject this guy, this is what happens to him. That left arm just goes up like this, and his right arm stays like this. Now if I was battling Rafi or Nick, or we were going to choose to do with this patient, the first and only thing that I'd want in my pocket is I'd say, we'll do anything you want, but I get to pick which shoulder, right? Because if I do this, and this guy does this, I can do anything the hell I want. I can release his biceps. I can do rehab. I can put a balloon in. I can put a tuberoplasty on, and they all work. There's all literature to support that. The problem is, is that if I get unlucky, and I lose the flip of the coin, and I've got this patient, all those are off the table. All of them. The left arm won't work, the tuberoplasty won't work, the biceps tenonomy won't work. None of that stuff will work if you've got a function in the shoulder. And you say, well, that's kind of an obvious thing. We kind of all know that, but the truth is, we don't know that. Because every study that's done in the literature either excludes all those patients of the ones that we're really talking about. They either exclude them, or they throw them all in together, and they say, hey, it works. And that is the biggest problem with our literature as we go forward. So in this guy, you take a look, and he's got these two choices. And again, I'd tell you which side I'd choose. On the left side, this guy's got a massive rotator cuff tear, but he doesn't have any DJD. He's got good motion. His guttale is zero to two. So he has good muscle and bad tendon. And I always say this, that hope lives in the muscle. Where there's muscle, there's hope. If you have dead muscle, you can't do anything with regard to anything to reconstruct this with regard to an SCR. So on that left side, he's a great candidate, in my opinion. On the right side, he's got a massive cuff tear. He's got DJD, at least a Hamada 3 on this guy, positive pseudoparalysis, bad muscle. And so I'd say, if there's no muscle, there's no hope. And if you try an SCR on this one, don't ask me how I know this, it will not work. He'll fail. Okay? So we've got to define our terms. Pseudoparalysis, when defined, is often said is less than 90. Okay? So this is really interesting to me. And you'll see why I got sort of in the weeds about this and a bee in my bonnet a few years ago about it. And this is what we say. If you start out with this guy with a left shoulder, and he's at 85 degrees, and you do whatever procedure de jure that you look at and you do it, and you get him to here to 95 at the end of the day, meaning you took him from here to here, you have cured pseudoparalysis. Now that's horse shit. However, that's exactly what every study in the literature that's looked at this reports on, because that's the definition that we're using. And that's why all of these discussions and controversies come up, because we're not strictly defining exactly what we talk about. So we would call it great success, but it's not. Also remember that this is not just a problem of elevation. It's external rotation. So you mentioned Joe was in the talk, and he said, don't do this in somebody who doesn't have external rotation. Right. You don't get it back. So the people that say, well, it's a rehab issue, I took away their pain with a balloon long enough to be able to get their deltoid and everything to rehab, and now that's why it works, I would say, well, then why doesn't external rotation work? You rehab that too. And that's because you don't. You're just doing a really good pain relieving operation. Now Nick Verma is with us. I promise you he is as honest as there is in our world. He will report it. I believe him when he tells us what he's seeing. And I think there is a place for this, and I'm anxious like the rest of you to see kind of where it ferrets itself out. For example, can we protect cuff repairs with this? Don't know. Can we use this in the partial repair issue? Don't know. So the data is going to have to lead us. But the idea that, and even I think Nick would agree with this, you talk about reversing pseudoparalysis, ain't happening. So we took a look at this and did a big systematic review of the literature, and what we found was, this is why I speak with a little bit of passion on this, is because we looked at every study in the literature, 16 of them out there with six different approaches, including nonoperative rehab, a study by Ofer Levy, a very well done study, where they looked at patients with quote pseudoparalysis, and they just sent them to rehab, and all those patients got better. In fact, the very best data in the literature is Ofer's study in terms of reversing pseudoparalysis with chest rehab. So Joe, with all due respect to his patient, you saw that guy, and at five years, he was here with the balloon. And you go, wow, that's good, but you guys have, and I have, we all have, those patients that we did a bicep stenotomy, and five years later, they're okay. Not everybody, but some. And those patients that just went to rehab, and it worked with a massive cuff tear. We don't know why some of those patients with grade four changes in infra and supra can still raise their arm, but if they can, then he certainly did a good operation. And in fairness to Joe, if I was going to do a balloon, and it worked for five years, I don't care why. We don't care why it worked. If you got five years out of a simple procedure like that, that's a win. So whether you did whatever you did is pretty good. But I think again, as Nick said, we have to be very, very careful about how we define it and how we limit our indications. So if they're all work, what should we do? We should define our terms. So the first thing I would just implore you about is a lidocaine challenge, right? So again, none of the studies that we looked at, all 16 of them did this. Now, if you want to see something funny, we published this paper in JSCS a few years ago, and Steve Burkhart, who's a great mentor to me and to many of us, wrote a absolutely ripping letter into the JSCS criticizing our study. And Steve has very, very strong feelings about it. He said, of course we do, and blah, blah, blah. So it's actually pretty comical because he's a very good writer, and he rips us a new one for some of the weaknesses potentially in our story. You also have to defend your, and I talked about functional versus not functional. So if it's non-functional, you're there. So here's a treatment algorithm for you to consider because I think this is where we have to get to because everything is inpatient selection, everything. So the first thing I would say to you is the first question you have to ask, and there's a little nuance here, but the first question you have to ask is, do they have significant degenerative joint disease or not? We published the first large series in the US literature with Burkhart, myself, and Dennard and our group, and we had a high failure rate in terms of the structural integrity of it. And some of those were mine because I didn't have an idea about the indications on it. And so I was doing it in patients that were too far gone. I learned that lesson early. If they have significant DJD, then I would tell you, do a reverse, please. Because the reverse, as you guys that do it know, is an excellent procedure with excellent functional outcomes, and it will reverse pseudoparalysis. So if you have somebody with significant DJD, don't mess around. Now somebody out there in the audience is thinking, well, what about the 30-year-old with DJD? Okay, you got me. Maybe we don't want to do a reverse on that one, so we might have to have a little. So there's always exceptions, right? But if they got significant DJD, do that. So if they don't have significant DJD, then my next question would be is, are they young or old? Are they active and active? And you get to define what young or old is, okay? Because if they're old and little functional, many of my patients are 65, 70. I live in Scottsdale, Arizona. We call it God's waiting room. And so those patients come in sometimes, and all they really want to do is put a dish on a shelf, okay? So this is not your pickleball player, which is also Scottsdale, Arizona. If you can't play pickleball, it's a surgical emergency for those that want to do it, right? I mean, these people are just insane about it. So I'm going to do this. Now, if they're older than 65 and they're inactive, I mean, even if they've got a repairable cuff in my hands, I'm pushing them to a reverse because that's one and done. And the way I do a reverse, I don't repair the subscap. That's a different conversation. And so I don't restrict their postoperative rehab at all with a reverse. So they're back to life. That's almost my fastest rehab of anything I do. Okay. But that's not what we're ever talking about when we're having these discussions, right? When we're getting together, what we're really talking about is this other group. The youngest patient who is active, then I would say, you got to know whether they're functional or non-functional. If they're functional, meaning that they can do this, and like I said, I don't care what you do. You can do a balloon. That's been in the literature now, thanks to Nick. You can do a biceps. Wallow and Walsh have two large series studies in there, double your constant score. You can build your muscle with PT. Any of the Bs will work for you. Okay. Any of those things are fine. But we're not usually talking about that either. When we get to this talk and these debates, what we're really talking about is this group, the non-functional ones. What do I do with the youngest patient who's active, who does this? How do I fix that? That's the hard one. So then my, I would implore you again, then, that this for me becomes a question about whether or not their cuff muscle is alive or it's dead. And again, where there's muscle, there's hope. If your cuff muscle is alive, then I think this is the perfect patient for the SCR. And for me, this is a home run. It works. It's excellent. And it will reverse pseudoparalysis. But look at the algorithm here. And I'm in a pretty narrow window when I get to the bottom and I'm offering SCR. If you have, your cuff muscle is dead, and this is another one of those, don't ask me how I know this, the SCR will not work. Now, remember, we do lots of patients who have SCRs that do this. They say, oh, I had grade three, four gouttelier changes. And look at this postoperative thing. And I say, where did they start pre-op? Because if they started like this, then an SCR can be just like a bicep snip. It works fine. But the true patient who's truly pseudoparalytic and their muscle is dead, it ain't happening. There's nothing to do. Burkhart used to say, I'd have to suspend my disbelief to agree with you. And it's true. I mean, it just doesn't work. So this patient where your cuff muscle is dead, that's where I think we talk about lat transfer or lower trap transfer. And I think once I understood this algorithm, it took me a lot longer than I'd like to admit. Once I understood that algorithm, then my success rates and everything else have gone way, way up. So I would just tell you that. So this is the patient that we're talking about today. The patient with no significant DJD, youngish, nonfunctional, and a live cuff muscle. If you have that patient in front of you, then I would tell you SCR is an excellent choice for this patient. OK. So how do we master the procedure? I'm just going to make one ploar. If you only hear one thing that I say throughout the technical part of this talk, I want you to notice the two sutures that are free there that are medial on the patch. Because in my opinion, that is the whole key to the procedure. And I'll show you why in a minute. So step one, you have to expose and you have to visualize. You notice that we're doing all these releases and the coracoid is critical. So get comfortable with exposing both the backside and the front side of the coracoid. Because if you do that, the backside is an excellent place for your middle anchor. And your front side of your acromion is right at the top of the subscap and is an excellent place for your anterior anchor. So you should preserve the cuff remnant and expose the glenoid, right? Coracoid base, coracoid root, and posterior glenoid, wherever that edge of that cuff that you're going to incorporate is, that's how you do it for your exposure. If you're not comfortable exposing the glenoid, or rather the coracoid there, that's what I tell you is your one critical step for that step in the procedure changes everything. The second thing is where to place glenoid anchors. So we started doing two glenoid anchors anteriorly. And occasionally, if you don't have a big cuff tear, then you sometimes will use two, but I almost always use three for this, okay? And then I would tell you this, for your anchors medially on the glenoid, follow the portals. Anterior goes anterior, posterior goes posterior, middle goes middle. Middle by middle, we talk about the nevizor's portal. If you try to put a middle anchor, or sorry, a posterior anchor through a middle portal, through a nevizor portal, you'll break right out into the cartilage. It's a very thin area. It's really tricky. So just make that nevizor portal. It really helps you later, like this one that you can see with the clear cannula there. And then you can get perpendicular to that glenoid every time. If you'll follow those rules, you'll never have a glenoid breakthrough, and you can keep your sutures separate and you don't end up with the suture salad. Don't ask me how I know that. Okay. So then here's graft prep. And this is what I said earlier about, please take this to heart. Those two free sutures medially on there, the one blue and the one white, I'm going to use to incorporate the native cuff. And I think that's the whole procedure, or at least part of the procedure in my hands for the person who you're trying to restore functional motion on. Okay. So passing. There's lots of ways to pass this. I've seen some of the most famous surgeons in the world do live surgery and get a suture twisted. And those of you that have done this procedure know that's a sad face day. There's no recovery from that, especially if you're using knotless techniques and it becomes really a long day. I've seen famous surgeons in live surgery, put the patch in upside down. I've jacked it up myself more times than I care to admit in terms of these things, and these can become really long cases. So if I was doing this live in front of you and I really was nervous about it, or I didn't have a ton of experience with this operation, I'd pass one suture through the cuff and take it in. If you do that, as you see here, I'm passing it with the middle portal. That's the only one in the graft as I start. And then you can fix that one in the middle. Once you do that, then just cuff repair around it. Now it's a little slower, right? Because you haven't passed all your sutures outside, but this is the one that guarantees you that you won't get your graft and your sutures twisted. So as you begin to do this operation, please start with one suture through the graft, bring it in, get that one secured, then it won't move on you, and then draw dots on your patches and then find your patches and just do a cuff repair. So that would be my pearl on that. Also, this is the key step. I told you if you only listen to one thing about the technical aspect of the operation, please listen to this. Note, I'm doing the lateral side here, but please note the medial, that blue stitch medially and the white stitch. And please note the remnant of the supraspinatus infraspinatus. We talk about, and I'm moving them outside. We talk about tying it to the back of the cuff. I don't think that really gives us much help, but I do think that if we can incorporate that remnant cuff that you see here to that white and blue suture, then we create an extension graft as well as an SCR. So here's what I'm trying to do here. When that patient's mind says, fire your cuff, the cuff still retracts if they've had any muscle at all. And again, they have to have a live muscle. So when they retract, it does this. If I can attach the cuff, the patch to the cuff, it will pull on the patch. And if I can attach the patch to the bone, I've reestablished the function of the muscle patch bone junction. And that's what restores motion on these folks. So the graft incorporation is the key. So you see, I've got the SCR picked, and now I'm taking that remnant medial graft. Don't really care where it goes to, it can retract all the way to the glenoid. As long as the muscle can contract, I can restore the muscle tendon unit by putting these pictures in here, if you will. So this is me repairing it over the top, if you will, as we go. And this is what happens when you can do it with good muscle, right? So this is a lady who's 54 years old. She hasn't lifted her arm in over a year. She was truly pseudo-paralytic like this. And we do this operation, and she comes back to me, and she goes, this is six weeks out. And she goes, doc, doc, look what I can do. And I said, don't do that. We're six weeks out. But since you did it once, could you do it one more time for the video? So I do that there. But realize, this is good muscle. If she's got dead muscle, I don't do that case for her. I can't do it. The final thing is I'll say patch thickness matters. And I think that when we take a look at the other criticism I might have about the balloon is, is that, yes, you insert it, and you blow it up. But then you retract fluid out, according to the manufacturer's recommendations. And when you report it out, do you know how thick it is? It's 5 and 1 1⁄2 millimeters. Rafi's patch is 3 millimeters, maybe 3 and 1⁄2. And that's forever. His patch lasts. So the big question we all have about the balloon is, why did you do a temporary balloon? Why did you do a resorbable balloon? Where is the permanent balloon? The answer is they don't have it. And they've got the IP locked up on it. Believe me, I know that, because I thought, oh, this is a great idea. Exactly, right? I went to a company that makes breast implants and testicle implants. And I said, I need either a really small breast or a really big testicle. And they go, they did. They were really interested in it. And they looked at it. And they go, no, they did a good job in locking up the IP. The thickness may matter, right? Maybe the function of the whole thing is, maybe the balloon is right. And I think that's one of the coolest things about this, is that it's forced us to rethink about, well, what is fundamentally the function of the rotator cuff? And if it is to hold the head down, then maybe all we need is a spacer. And certainly, Rafi's data would sort of lead us in that direction. The early balloon data would lead us there. We just don't want it to be permanent. We need it to be permanent, right? So that's where we are. So partial thickness matters. We've seen this from Mejada's work, where 8 millimeters is better than 4 millimeters, where tensor fasciae latae is better than dermal allograft. I would tell you, if you have a patient that insurance can't do a patch because they're expensive, about $3,500, take a little TFL or take an ITV. That's an autograft patch. You can do exactly what Rafi showed you with covering the tuberoplasty with that. And it works very, very well. So for those patients who say, hey, look, I can't buy the patch, well, OK, I got something out of your hip. It'll work fine. Just as well. Maybe better, OK? So this is our approach to this. When I see a patient who has hematoma 2 or 3, I do an SCR on them. But we call this an SCR plus. And so not only have we done the SCR below, but then we add this acromial resurfacing to the top. Now, if you do SCRs, you know that you always toss half the patch anyway. You cut the patch, and then you throw the half in the garbage. And I thought, well, gosh, why don't I just take the other half and put it on the acromion? And this essentially doubles the thickness of my graft, taking me from 3.5 to 7 millimeters, which is thicker than a balloon. Plus it gives me all the benefits of the potential SCR. So lesson learned. Prepare, prepare, prepare. For those of you that have done this, you know this is a game-changing operation. But the indications are absolutely critical. It is a technically demanding operation. The first time you do this should not be when you're in on a patient. This is one where you can go to a lab. There are lots of labs out there that you can fiddle with it and get comfortable with it. There are some tricks to this operation for sure. The evolution of this is necessary. The way I do it now is very different than the way I did it seven years ago when we started doing these as well. And so with that, I say thank you and good luck to you. Thank you. Yes, sir. In the back. How do you attach it to the undersurface of the acromion? That's pretty interesting. How do you do that? Yeah. So I've gone to implantless. And so the technique that we described is that we just take the patch and we place it on the surface of the acromion. And then we do the implant. mattresses in the corners, okay, and then you just go through the AC joint on anteriors medial, just off the anterolateral corner of the acromion anterolateral, same thing posteriorly, and then you bring them up and I make one little incision in the middle and then you can just fish out your sutures essentially and tie it over a bone bridge. You know I did when I started out but in truth I the usually the space is plenty wide to be able to get through that, yeah. Yeah so I generally will do a double row and the reason is is that when I first sort of thought about doing SCRs I went to Jed Kuhn, you guys know Jed, and I said hey I'm thinking about trying this and I said what do you think and Jed said I think you're putting dead chewing gum into a shoulder, that's what he said, and I thought well if Jed disagrees with you it's a little bit like disagreeing with the Pope, you do so at your own peril, so I was like yeah I don't know about that, so I the problem is we got to get this thing to heal and so you know double row is pretty good and you never run out of space or issues because you can always just make the patch longer, makes it a little more technically difficult because if you over cut the graft and you know then it's sticking in that lateral row and sometimes that's hard to you know kind of hard to repair but yes I'll do a double row if given the choice, yeah. Perfect, oh yes ma'am. Yeah, it's a good question. The choices are, number one, maybe nothing, right? So I have had one of those rip apart. I've done it a couple of times where I just did the acromial resurfacing and I did have one patient where the graft dislodged. It never healed and so that one's on me. But I would say that if I do think they heal, I think that the data has been shown in animal models as well as humans and, you know, many of us have published data on, yes, this thing does heal. So if you can get it to heal the bone, I think the idea is that you decrease the stress in terms of the contact of the bone on that and spread it out over the course of that. Maybe a little bit of a spacer effect, if you will. I think that's the effect. Yeah. So you put the aloe vera at the end, the remnant rotator cuff at the top, and then you... Yes, but the remnant rotator cuff is usually medial. And then we take the rest of the patch and we flip it and we come up here. So there are some that don't think that it matters which way you put the patch in. I tend to think it matters. And the reason is, is I think that the dermal side, if you will, is akin to vascularization and healing. And so, you know, we can never... People talk about folding the patch or doubling or tripling the patch. And I don't know of any great data on that yet, but I would say that I don't love that idea because you're in a conundrum. You either fold the patch where you've got healing side up and healing side down, in which case I worry about scarring, or you put epidermal side to epidermal side and then I worry about healing. So this SCR plus allows us to put dermal side down and then dermal side up, which then gives us that articulation between two skin surfaces, if you will. But it'll remodel, so who knows? Yeah. Excellent. Thank you very much.

pseudo-paralysis

rotator cuff tears

functional cuffs

non-functional cuffs

glycocaine injection

superior capsular reconstruction