So, my job here, really, is to talk about the utilizations of graphs. Dr. Toro already just gave a very, very good talk about primary repair, and really even showed some of the graphs that have been utilized more recently. And I think this is a pretty controversial subject, particularly related to the indications of when you should use a graph, and if you do a graph, what technique you should be utilizing. My disclosures are updated regularly on the AOS website. As we all know, the ultimate goal of a rotator cuff repair is really to get that tendon to heal to the bone, because that provides probably better function, better strength, and likely better long-term durability as well. The difficulty is that re-tears happen. Even in small tears, it can happen, but obviously, more likely in large and massive tears as well. And part of the reason for that is this compromised biological healing environment. And when we are dealing with tears, particularly with chronic tears or revision situations, we are commonly dealing with poor quality tissue. And that's where graphs can sometimes come in, because graphs can provide us both a biomechanical and biological improvement to that healing environment. We know from a biomechanical perspective, generally speaking, these graphs are in fact have poor mechanics, but when we use them as particularly augments, it can increase the strength of the repair, both cyclic loading and load to failure. From a biological standpoint, which is probably even more important, we know that because a lot of the 3D architecture is maintained, it can support vascular and cellular in-growth, and we've seen that with a number of biopsy-type studies. The difficulty is, of course, many of these scaffolds are very different, and so we have to be very careful when we're reviewing the literature and trying to figure out the utilities of these graphs, because there's differences in mechanics, processing, and sterility, which could affect your results in your particular patient. So this is kind of my algorithm, which I think about when I'm looking at a massive tear. This is, of course, I would call this probably level six evidence, because there's really no data behind it, but it's what I think about when I'm in a clinic, and in particular, what I'm going to be dealing with is this group here, where patients are generally less than 70. You can change that age, what you think is appropriate for RSA, nor arthritis. You're going to have irreparable and repairable tears. I particularly look at the infraspinatus, guttale, and also if the patient has significant lag signs. So here's our first case, a 50-year-old female. She happens to be a family doctor in our town. She actually fell in Europe three to four months prior while skiing in Austria. Incredible system there, because 48 hours after she fell, she actually had a rotator cuff repair performed. She had been doing physical therapy for about four to five months, but continued to have increasing pain and night pain when she showed up to my clinic. You can see here, this is her physical examination and brief. She has standard things, positive impingement signs, she has a weakness, her motion's a little bit stiff, but she's only about four or five months after surgery anyways, but she was quite concerned with regards to this. She actually saw one of my sport medicine colleagues prior to seeing me, and she had some investigations performed. You can see in her x-rays, they're not that contributory, but there's a little bit of a blush on that lateral deltoid. I'm not exactly sure what that is. We actually did an ultrasound, which suggested a recurrent tear, so we followed it up with an MRI, and you can see there's probably a recurrent tear there. It looks like some retraction of the tendon edge there, but you can see here, see some of her anchors from previously, but one of the anchors is actually incarcerated within the deltoid, per se. So she obviously has a recurrent tear and some loose anchors, and she's about four months, so we decided, of course, to go back in, and so you can see here, this is her shoulder left side. She already had failure of her cuff. Some of it is tendon failure from suture. Some of it is bone from tendon failure. We're going to remove all of her previous fixation. I thought it was best to stage this lady just because of her stiffness, per se. I wanted to rule out any infection and get her motion back, so we did a capsule release, and then we decided to come back three months later. You can see the relatively large size of her tear. It's actually relatively good tendon quality, though, which was a surprise because some of the sutures had pulled out of the tendon. You can see it's reducible to the bone bed. So we decided to do a primary repair on her, replace the medial anchors and medial sutures. We're tying the ones that reduce the tendon to the bone, but we're going to save some of our sutures essentially for an augmentation graft. In my philosophy is that if you're doing a revision case and it's large and it's massive, you have to do something different, so doing a primary repair again in isolation is unlikely to be successful because it's already failed once. So in this case, we're going to do an augmentation repair, a human dermal allograft on top. You can see how we lay it down. In this case, we're going to do a pseudo trans-osseo-requivalent repair of the graft on top of the actual rotator cuff repair, and you can see the type of repair that you can achieve. So that's for this patient. I think that in her, she was young, she had no arthritis. She had a repairable tear. I didn't show the fat infiltration views, but it was essentially still an acute tear, and so we decided to do rotator cuff repair and augmentation. So my indications for an augmentation graft are essentially large and massive tears, chronic tears, particularly revision situations, still good muscle bulk, particularly related to the infraspinatus tendons. You want to save that tendon and tendon repair to bone, and of course, it has to be repairable. Can grafts improve outcomes? Yes, they can. Again, you can see here in this meta-analysis of six comparative studies, comparing standard repair to standard repair with grafts, that it did improve healing and improve patient-reported outcome measurement tools. This is probably the best study out there, prospective randomized trial, using some might consider an inferior allograft, but it's still human dermis. You can see the healing rate was significantly increased, 85 versus 40 percent, and of course increased patient-reported outcome measurement as well. Now, one of the difficulties when you're trying to use these types of grafts, of course, is that it can be somewhat technically demanding and time-consuming. So since then, really, there have now been some simplified augmentation solutions. You can see in this technique here, it's still human dermis, and they actually have these tubes of human dermal allograft, which can slide over the suture, and essentially, particularly if you're doing a trans-osseous equivalent repair, you can essentially lie these over your graft, per se. I haven't seen a lot of clinical results for this type of technique, but it is out there. This is another type of technique using a bio-inductive collagen implant. This is actually a xenograft. It's bovine Achilles tendon, and this is what Dr. Toro showed you earlier. It's initially indicated for partial thickness tears, but people are now putting this on top of full thickness tears. The greatest thing about this device, as Dr. Toro suggested, it's very easy to deliver, and essentially very easy to fix down. There are both tendon staples and bone staples to secure it according to where you want that graft to lie on top of your repair. So here's a case of that 64-year-old female, right-hand dominant, right shoulder. It's a work comp case. She had a fell as a letter carrier. She did do some non-operative treatment, but continued that pain and discomfort. Her x-rays are essentially no arthritis, not that contributory. Her MRI, you can see she has a large-ish size tear, mainly isolated to supra, maybe a little bit of upper infra, but you can see the muscle quality, the muscle bulk is still relatively maintained. The supra might be down, but it could be related to more retraction rather than atrophy, per So you can see her on her surgery. She actually has a delaminated tear. You can see she has a superficial bursal surface and a deep capsular layer. Interestingly enough, the deep capsular reduces in a medial to lateral fashion, while the superficial bursal layer reduces down to more of a side to cell, almost like a T-type fashion. So we're going to first fix the medial aspect deeply. So we pass our medial mattress sutures, and then we're going to now separately pass it through the superficial bursal surface layer, so that we can get kind of a medial to lateral shift deep, but an anterior-posterior shift superficial. Now we're going to prepare the lateral aspect of her repair, replace the lateral anchor, and we're going to close this down more in a side-to-side fashion, which is what the superficial bursal layer is mobile with. So you can see our repair, and we only initially tie down the lateral aspect first, and you can see when we tie this down, it actually reduces the medial aspect extremely well. You can see the medial sutures are essentially lining up almost anatomically. We're going to tie those medial sutures down, which of course also reduces the deep capsular layer, and then we bring these out far laterally for another anchor, just to provide some compression on the footprint as well. The repair looks relatively good, but in this particular case, because of that delamination, we thought best to try to augment this person, particularly a workers' compensation patient, and so we decided to place another one of those bioinductive implants on top to hopefully enhance the healing process. So there is a recent study looking at this for full thickness, large and massive tears, which they're able to repair, but use this bioinductive collagen implant as an augment, and you can see, interestingly enough, 16 of these retrovision cases, which I think are the worst, and they had a healing rate of 96%, which I think is very impressive. Okay, so what happens if you have a tear that's irreparable? So you can see we're going to go down this algorithm here, an irreparable tear. Importantly, I'm going to talk about situations where there's no significant lag sign. So I think if you have a massive tear, significant external rotation lag, infraspinatus cutalea greater than three, and your subscap is irreparable, I think you might be talking about a different operation. You might consider a tendon transfer. If, however, you don't have an external rotation lag and the subscap is either intact or repairable, that's when we're going to talk about either doing a bridging graft or an SCR for these irreparable tears. So I think there are a lot of options out there as well, and you know, there are some patients who do not require some of these massive reconstructions. You can think about even doing a partial repair like Dr. Toro has suggested, or even just a debridement per se, particularly in your older patients where pain isn't really their issue. And now we have, of course, have these subacomial balloons, which may be another option for these older type patients as well. We're of course going to focus on this option. So you can see here, here's our first patient. A 41-year-old female. She's right hand dominant, right shoulder. She works as a merchandiser at a drugstore. She had an injury back in 2018 when she was catching a bag that was falling from the shelf. She had a cuff repair just last year. However, post-operatively, unfortunately, she had a fall at five weeks. She continued to do rehab, had ongoing pain, painful arc, mid-arc catch, ultrasound showed actually recurrent tear. Clinically, she regained essentially most of the motion. Pain was her major complaint, in fact, although she had some difficulty with strengthening because of the pain, she felt as well. Radiographs are relatively non-contributory. Maybe there's a little bit of elevation, but the acromi-humeral interval is relatively well-maintained. On her MRI, interestingly enough, you can see here, there looks to be some tendon attached to the bone, but it's hard to know if this is good quality tendon. Maybe it's actually a recurrent tear. You can see that her muscle bellies down here, the supra does have some fang-infiltration as of the infra. It's probably somewhere around two, maybe three. You can see here's our surgery. In this case, she does have some tissue there, but it obviously doesn't span the defect very well. It's very thin and it's very friable. I don't think she had a very robust healing response and or she had, in fact, a failure in continuity. This is the type of tear that we ended up with. You can see we can reduce it to the bone bed, but the tissue quality isn't the greatest and she's actually failed a previous repair, particularly this was on the OR report reduced as an L-shaped tear. So in this particular case, we decided to do a bridging graft. So we're going to measure our size, place all of our medial sutures. We like to use a syringe to deliver our grafts. We think it's a great way to actually organize our sutures. We're going to shuttle the graft into place. In this particular case, we like to tie our medial sutures first and then fix it laterally as well. Usually we do a double roll laterally and then tie simple sutures circumferentially. It's a human dermal allograft again, and you can see this is the type of repair you can achieve. Just this is type of a bridging graft in those situations where you have a large to massive tear. So bridging grafts, of course, are traditionally what people have been doing prior to SCRs description. It's my indication for this procedure, a massive irreparable tear, no OA, no lag signs, coma humoral interval, usually greater than seven or just slightly less than seven, five or six, depending on what type of partial repair you think you can achieve. I think good tendon quality is extremely important. In some of these revision cases, the tendon quality is extremely poor, and I think you're better off fixing the bone immediately. They should have, of course, good passive range of motion, and particularly when pain is the number one indication, I think that's your best option for the bridging graft. Can bridging grafts heal? Yes, they can heal. We reviewed ours, 34 patients, about 82% healing, 18% were retorn. You can see the type of healing you can get when you resculpt these patients as well. Looks relatively good. When you compare the indications of human dermal allografts, that is augmentation versus bridging, in fact, bridging grafts, even though we know they're not exactly FDA approved, in fact, do extremely well. They do as well as augmentation grafts. In fact, it may be a slightly better healing rate, although it's hard to compare because the articles, as you might imagine, are quite heterogeneous. So the question, of course, now is what if you have a patient with significant proximal human migration? That is, you can see here, in fact, we did a bridging graft, but there's still some migration of the humerus, loss of the chromohumeral interval, and also loss of the glenohumeral fulcrum of motion. And so that's the situation here where we're down this algorithm here, again, a chromohumeral interval less than seven, and that's when you might consider doing a superior capsular reconstruction. So here we have a 59-year-old male, right hand dominant, left shoulder, slip and fall. About two years ago, he has complaining of pain and loss of strength. He's done some non-operative treatment, which has unfortunately failed, enjoys doing martial arts. His range of motion is as seen here. Augmentation is actually somewhat weak, three out of five, but there's no lag, in fact. He doesn't have any subscap signs. You can see here, you know, the x-rays aren't perfect, but there is some narrowing of the chromohumeral interval, maybe a little bit of even early arthritis. MRI shows a massive tear, supra, infra. You can see there's atrophy and fatty infiltration of the infraspinatus muscle belly as well. Subscap looks good. Subscap intact is important, as we know. So you can see this person's surgery. You can see the supra, maybe a little bit of upper infra involvement as well. In this particular case, we're going to do a superior capsule reconstruction. You know, the technique for this is somewhat difficult, but if you are meticulous with your suture management, I think it can be performed by almost anybody. I like to do a double pulley medially and a double pulley laterally, then circumferential repair of the graft around the tendon. If you can get a repair of the tendon on top of the bone, I think that's even better. On top of the graft, you can see this patient's outcome at a year. This patient is happy with less pain, and you can see that the graft has healed with the gland and into the humerus, and potentially, you can look at this, you might think that the chromohumeral interval has been improved as well. It's super difficult to know, however, what the longevity of that increase in chromohumeral interval is, particularly when utilizing human genital allograft. So we know that Mihato was the one who, of course, first described the superior capsule reconstruction, and his results were extremely very good. He, of course, decided not to use the graft to extend the tendon to the bone, but really attached the graft from the glenoid to the humerus. We know from a mechanic standpoint that when you utilize the graft in that particular manner, it has decreased superior translation and decreased subacromial contact, even when compared to a bridging graft. His results, of course, were extremely, extremely impressive. Back in 2013, you can see his initial results of his first 24 patients, 83% of them were intact, and the chromohumeral interval increased from 4.6 to 8.7. His longer-term studies, you can see 30 patients, five-year results, again, very good results, 10% re-tear rate, and again, maintenance of the chromohumeral interval as well. Unfortunately, the U.S. experience has not been as good. You can see here, these are Dr. Burkert's results, about 60 patients. There's improvement clinically in these patients. The ASDS score, however, is not as high as what was reported by Dr. Mihato, and unfortunately, only about 45 of the grafts actually healed, and this was associated with subscap atrophy. You can see here, the chromohumeral interval, while transiently increased, was not maintained even at relatively short follow-up. This is a similar experience out of Chicago. You can see 54 patients, 11 of them were failures, about a 20% failure rate. The factors that are associated with failure were female gender, and again, if there was a significant subscapularis tear. So the integrity of subscapularis is very important as far as the results of the superior capillary reconstruction, but the back of the shoulder is also very important here as well. You can see in this study here, 36 patients, superior capillary reconstruction was performed with both fascia lot and human dermal allograft, 36% of them, in fact, had a re-tear, that is 13 patients, and that was associated with the posterior integrity of the rotator cuff, that is the infraspinatus per se. You can see here that when the infraspinatus was intact, the healing rate was 72%, when it was torn, it was only 20%. So some of the differences between the U.S. and maybe the Japanese experience could be, of course, the graft that is being utilized. Most commonly in North America, human dermal allograft is being utilized, whereas in Japan, fascia lot is being utilized. You can see from a biomechanical standpoint, while both can improve superior stability, fascia lot does this much better than human dermal allograft, and then human dermal allograft tends to elongate when under load. So clinically, is there a difference? It is somewhat dependent. You can look at these studies here, seven studies, people tried to compare fascia lot versus human dermal allograft. All of the studies had improvement in as far as forward elevation and patient reported outcome measurement tools. However, there was a suggestion that there was a better healing rate on MRI. You can see the re-tear rate for fascia lot was 5 to 32%, human dermal allograft was 20 to 75%. And unfortunately, as you might imagine, these studies are too different and they're difficult to compare, so we do not know if that healing rate is in fact significant. What about when you compare bridging graph versus SCR, because that, to me, is one of the indications that is unclear when to do which procedure. So this is another study, a meta-analysis, 23 studies. You can see the SCRs have a lot shorter follow-up than the bridging graphs. But interestingly enough, when you compare the studies as far as the improvement in the constant score, ASES score, pain, and active external rotation, there's actually a significant difference which actually favors the bridging graph, which was a little bit of a surprise. But it's hard to know because, as you might imagine, the indications can be quite different for these two types of procedures. Many of the patients in the SCR group had more severe rotator cuff tears as far as their fatty infiltration and pseudoparalysis. We actually just finished a prospective randomized trial comparing superior capsule reconstruction versus bridging graphs. We actually randomized 50 patients. The average age was 60. The vast majority were male, all hematoma, less than three. We did use human dermal allograft. They were all intraoperatively randomized to either procedure. And interestingly enough, at two years follow-up, there was no significant differences in a patient-reported outcome measurement tools and as well the chromohumeral intervals. We had about a 70% healing rate in our graphs. There's no significant difference when we compared bridging graphs versus SCR, even with MRI healing. Interestingly enough, if you had a healed graph, whether it was bridging or SCR, they did much better than a retorn graph. And this was correlated with the integrity of the subscap and as well the posterior cuff. So that's really important when you're considering these types of graphs. So I think in conclusion, graphs can be helpful. Obviously, we need more studies to help us to help determine whether these graphs are indicated in regular primary repairs, but also in revision situations when we have massive and irreparable tears. It's still unclear to me which graphs to utilize and which procedures to use in that particular patient, but I hope that algorithm helps you somewhat. Thank you very much. Thanks, Ian. That was great. All right, we're going to move on.

graphs

rotator cuff repairs

tendon healing

re-tears

biomechanical improvements

biological improvements