I'm going to go ahead and get started. Sorry. I'm trying to catch my breath. So these are my disclosures. Massive cuff tears are a challenging problem, and several treatment options exist. And Thierry Mihata's description of the SCR has really opened up the door of multiple different treatment options that are available. We have to stop and ask ourselves at first, where is the pain coming from in massive cuff tears? Is it bursitis? Is it myovitis? Is it the biceps tendon? And I will submit to you that some, if not most, of the pain comes from bone-to-bone contact between the greater tuberosity and the acromion in a massive cuff tear. This is a cuff-deficient model from Gus Mazzocca's lab, and you'll see that without the cuff, that as soon as the deltoid fires, the humeral head gets pulled up, the center of rotation gets elevated, and there's bone-to-bone contact between the greater tuberosity and the acromion. Here's a clinical example of an intact cuff with 10-degree active abduction view, the X-ray on the left, and you can see how the greater tuberosity is rolled underneath the acromion without making contact. The center X-ray is a patient who has a massive cuff tear without activation of the deltoid, and there's plenty of space between the humeral head and the acromion, but as soon as they fire the deltoid, there's contact between the humeral head and the acromion. We've all seen these cases of massive cuff tears. There's acetabulization of the acromion, and that's from continued rubbing of the tuberosity against the acromion, and we all know that bone-on-bone hurts. So what is biologic tuberoplasty, where did it come from, how does it work, and when should you use it? It all started when we were following our patients who had undergone SCR at Kaiser Permanente. We had 53 patients, and we obtained post-op MRIs on them, and 62% of them had a graft tear afterwards. Only 38% had an intact cuff, and out of those 62% who had a graft tear, not all of them did poorly. So we're scratching our head and trying to figure out why that is, and we looked at the location of the tear. So the majority of the tears were from the glenoid, about 20% were mid-substance, 23% were from the tuberosity, and there was one case where the graft was just dissolved or gone away, it was absent. And we looked at those carefully, we classified it, we published our results, and we found that there's three distinct categories. One where the graft was intact, and the other was when the graft was torn, but it left the tuberosity covered. So either a tear from the glenoid or from the mid-substance, and the third was where the graft was torn, leaving the tuberosity bare or uncovered. And the clinical results, the functional outcomes were pretty amazing, because the patients who had an intact graft had the same outcomes and improvements as those where the graft was torn, leaving the tuberosity covered. And the ones that had the tuberosity bare and uncovered did poorly, did not improve, and did significantly worse compared to the other two. So here's an example of a patient with an intact cuff, he has full active elevation, he has no pain, he's very happy with the procedure. Here's a patient who has a tear from the glenoid, but the tuberosity is covered. He's very happy, he can elevate his arm, he has no pain, and was very happy with the surgery. And this patient had a tear from the tuberosity, you can see that she can't actively elevate her arm, and she did poorly, she went on to a reverse. So we've described this, I coined the term biologic tuberoplasty, and I feel like in those situations where the graft tears, the biologic dermal allograft is acting as an interpositional tissue that prevents bone-to-bone contact and provides clinical improvement. And to some degree, if you think about it, even a latissimus transfer or a lower trap transfer, you're putting a giant biologic tissue on the tuberosity. So yes, it does give you functional or active external rotation, but it is preventing bone-to-bone contact, and even to some extent the balloon is doing the same, it's preventing bone-to-bone contact. So I've described one of the techniques that I've used to do this, but here's a very simple version of it. I just measure the tuberosity, I tend to undersize it because the graft stretches, I luggage tag the four corners of the graft, prepare the tuberosity, I'd run the burr on reverse so I don't take too much bone off, I place a center knotless anchor, that's going to be like my traction suture to help bring the graft in and bring the sutures out of the outer cannula. The repair stitch is placed in the center of the graft on the medial edge, and then passed with a loop stitch from the same anchor, and by pulling on the pull stitch, that brings the repair stitch into the anchor and locks it in. So you have a closed loop now that will help bring the graft into the subacromial space. This is an eight millimeter cannula, so there's hardly any resistance with it. This is a three millimeter dermal allograft, the same that's used for SCR. And then I essentially use punch-in anchors to fixate the graft in the four corners of the tuberosity. This is a little long, but this is the final anchor I'll show you. So just, we're all familiar with these lateral side anchors from double row repairs, but that's the technique. So eventually you end up with a picture like this, where the entire tuberosity is covered. So what's different about it though is the dermal allograft loves to stick to tissue, it loves to stick to bone, so I just immobilize them for three weeks, and after that I start pendulum exercises, passive range of motion three to six weeks, and then active and active assist at six weeks. So it's a much, much faster recovery than an SCR or a rotator cuff repair. Here's some post-op MRI examples. Every single one that I've done, I've obtained a post-op MRI at three months or six months, and the graft is adherent to the tuberosity, it hasn't sheared off. And here's a patient of mine that lost his insurance, but a year after, sought out my physical therapist, sent him a video, and this is what he wrote in email, that his arm feels great, his velocity is really good for a seven-year-old guy, and good enough to throw the ball by high school age kids, so he's very happy with the procedure. On the other side of the Atlantic, in England, and on the other side of the subacromial space, Matt Ravenscroft has described bursal acromial reconstruction. So instead of covering the tuberosity, he's covering the undersurface of the acromion. My challenge with that is that the sutures have to be placed percutaneously, and then you have to go underneath the skin and kind of retrieve the sutures and tie knots on top of the acromion all subcutaneously, so it's not very easy to do, and it's tough to find those sutures. The advantage is that there's no implants required, so if you have someone who has really soft bone and cannot retain anchors, this is a good solution. This is his work. He's done biomechanical studies, he's described the technique, and he just anecdotally presented this at one of the commercial vendors' websites, but he has done it on 78 patients, all had MRIs at three and six months, the average age was 78, so significantly older patients, but there was significant reduction in the pain scores and improvement in his Oxford shoulder scores with his procedure. So my indications for biologic tuberoplasty obviously are patients with massive cuff tears. Hamada 1s and 2s work best. I do not do it on Hamada 3s. They should have no arthritis, they should have an intact or repairable subscap, and no pseudoparalysis. If they're under 70, I still perform SCR. I think that's a very good procedure. I only do it in elderly patients who have poor bone quality, or if I'm doing an SCR and the glenoid anchors keep pulling out, and I'm already there, I have a dermal allograft, the bone quality in the glenoid is poor, I go ahead and do a biologic tuberoplasty. If the anchors don't hold in the tuberosity, that's when I would do a bursa lacromial reconstruction. That's my bailout. So this is my treatment algorithm. If they're under 70 and they have no arthritis, Hamada 1s and 2s, they're lacking external rotation, I would do a lower trap transfer. If they have the same no arthritis, Hamada 1 and 2, I do an SCR. If the anchors pull out from the glenoid, I would do biologic tuberoplasty. If the anchors pull out from the tuberosity, then I would do a bursa lacromial reconstruction. If they're under 70 but have arthritis, I think reverse is the best choice. Even if they're over 70, my first choice is a reverse. They do so well. But if they don't want an arthroplasty or they're not a candidate for arthroplasty, they don't want to undergo the physical therapy and the rehab for it, if they have good bone quality, I would do biologic tuberoplasty. If they have poor bone quality, then that's a good candidate for a bursa lacromial reconstruction. Thank you very much. Any questions about this? While we're changing computers, Rob, that's excellent. Let me just ask you about your rehab. So, why do you bother with the immobilization at all? I mean, one of the advantages of this may be that you can let these guys move right away. Yes. Would you consider doing that and just tell them sling for comfort and then fly? That's a good question. I think I'll get there. I went from immobilizing him for six weeks and then down to three. I'm a little concerned about my initial fixation because it's just pushing anchors. They're not twisting anchors. We just wanted to make a procedure that was easy for anyone to do and kind of be as quick as a balloon. So we try to do it. I can do this in under 10 minutes. And we're even thinking of doing just four anchors instead of five, so eliminating that central anchor. So, if you start moving it right away, we're worried about that shear of the dermal allograft rubbing against the acromion and kind of pulling it off. I chose three weeks because I know at three weeks that dermal allograft is going to be stuck to bone. It doesn't even need the fixation anymore at that point. That's my rationale. It's interesting, JT. We'll probably have the same discussion when we talk about the balloon, which is how fast can you go with the rehab. And anecdotally, I've seen that if I've gone too fast, the study was four weeks, and as we've tried to accelerate that based on post-market usage, I think the results have dropped off a little bit. So I've gotten conservative again. Well, that's crazy to me, because your balloon, especially the balloon. Yeah, it's not fixed. It is what it is that they want. Yeah. It doesn't make any sense to me that you have an advantage by holding on these. Yeah, I don't. Yeah, I mean, again, I'm just talking anecdotally. We have a study that's starting now that will look at accelerated versus delayed rehab. So we'll probably have a better answer at some point, but I'm kind of where Rafi is even with the balloon, which is two to three weeks of immobilization. I followed Rafi's lead. I wasn't smart enough to think about slowing him down. And it's made a big difference for patients to be able to move right away. So, and I haven't seen any failures with it. Yeah. Yes, sir. How do you code that? That's a great question. I, the system I work in, which is a large HMO Kaiser, it's all in-house. I don't have to bill, get insurance coverage and stuff. So I don't know if you guys can help out with that. Is there JT, what are you? Do you have any codes? Yeah. Yeah. I mean, if you just tack one of those, it's like, you know, it's like, you know, it's

massive cuff tears

SCR

biologic tuberoplasty

treatment options

bone-to-bone contact