this morning was to talk about when we start thinking about reverses for these massive tears. What did you do differently? There we go. Oh, he's got it. Okay. So here's my disclosures. So we talked about surgical treatments for rotator cuff tears. Both Ian and Joe talked about all these patches and SDRs and all those things, and all these factors on the right pertain to this. And I do all of these options. Half my practice is doing cuffs, half of it's doing reverses. So whether it's a partial repair, regenerative graft, augmentation, SDRs, I think if you're going to be a shoulder surgeon, you need to have all of these things in your pocket. One thing I do want to mention about the subscap repair. So if you code 29827, it doesn't matter whether you do a little simple crescent tear or you do a massive tear, you're going to get paid the same. You don't want to do that. I do send the extra time. So in my procedures, I'll put arthroscopic repair, the subscapularis, infraspinatus, the supraspinatus indicate that all three tendons are torn. I'll say the reason for the 22 multiplier is that multiple approaches were necessary to repair the tendons independently. I do that every time I do a subscap repair. You can also add, you know, it took me approximately 20 more minutes to do the case. And my biller says we get paid most of the time. So get paid for the extra work that you do. So indications for reverse arthroplasty. There's a number of them now. As you all know, we do them for approximately, here's fractures, rheumatoid arthritis, but we're going to talk about the massive rotator cuff tears and grossly deficient rotator cuffs. And the patients must have a functional deltoid. So really, my indication for reverse is when the patient can't raise his arm any higher than the tattoo lady can raise her leg, it's time to do an operation. So I submitted that to ASES, and they didn't think that was enough. So we decided to do a study. So the 2020 Near-Circle Clinical Study was the treatment of massive irreparable rotator cuff tears. And our charge was to have, to develop a consensus, and Peter Millett and I were the co-chairs. So the Near-Circle is a vision of Frank Cardesco, previous president of ASES. There's approximately 110 shoulder and elbow specialists in that group. It recognizes their service to ASES, and there's a criteria to get in. And the challenge every year is to do a consensus topic and to use a Delphi panel to determine a consensus of this Near-Circle. Inaugural meeting was in 2019, and that was on treatment of the first-time shoulder dislocator, and then the massive tear was the second one. So again, Peter and I were the co-chairs, and then here are the other members of the committee. And the committee required you, we had monthly phone calls. We had several email things all through the month. We did all these surveys, and this committee really worked hard to participate in getting this all done. Our manuscript has now been accepted by JSCS, and I just got the final thing from Bill Mallance that should be out any month now. So we've already gone through all these challenges and all the different treatment options, and we wanted to include all of these treatment options in this, including tendon transfers and SCRs and then reverse shoulders. So the Delphi process is, it's widely used in industry, in many different industries, and it's based on using a panel with high expertise. You have anonymous participation through questionnaires. You do multiple rounds of questionnaires, and our Near-Circle committee organized and structured all of these questionnaires and responses. Then it's analyzed statistically, and then you determine what the factors are and then base your conclusions on it. So it's a very rigorous type of process that we go through. So we had 110 members. We sent first questionnaires to determine their qualifications and ability to participate with the selected questions, because we know that we have some members that just do arthroscopy and they don't do reverses. Some people don't do patches. Some people just do elbows. So we wanted to make sure we had the right thing. Our next round was open-ended questions to determine ranking of treatments and what clinical factors we need to look at. Round two was ranking these factors according to the treatment and then coming up with clinically meaningful scenarios. So first we had to have a definition. So we used, there's a merit definition that came out and others in the literature, and we wanted a symptomatic non-arthritic shoulder greater than a two-tendon repair, which was defined as retracted to the glenoid rim on coronal and axial planes, and is irreparable anatomically under any circumstances. So you could get a repair, a lot of us could do partial repairs and things like that, but we weren't going to get it anatomically. And failed non-operative treatments. So that is the first question on whether you do surgery. So we sent it out to the 110 members of the Near Circle, and we asked them again if they were competent to comment on this. We asked how many they had done in the last year, ranked the importance of different features, and then again we had our open questions. So 72 out of the 110 reported that they had enough experience and expertise to participate, and we defined our massive tear, as you saw before, and here were our six treatment options that we were going to discuss and evaluate. So continued non-operative treatment, arthroscopic beam, or partial repair, including a possible biceps tenodesis, partial repair with graft augmentation, SCR, tendon transfers, and reverse shoulder. So we listed a number of factors, and we gathered this from the first survey, diabetes, smoking, statin, use, all this kind of stuff, and then we sent that out in our first survey to determine which ones we'd want to use. And this is one of the things that Adelphi, the process really doesn't define very well as you start to trim down what your factors are going to be, where that line should be. So we looked at this and kind of statistically looked at it, and we figured that the top seven were the most important. They were in ranking dynamic instability, which is intrasuperscape, pseudoparesis, age, Gattaglia classification, history of previous infection, demand, and whether or not there was an intact subscapularis or repairable subscapularis. So we sent out literature reviews. So everybody on the committee was assigned to a different topic, and we had two or three people working on literature reviews. Everybody had to report back in, and then we sent those summaries of the literature reviews out to the remaining near circle so they could review those, and then they could rank those factors based on what our results were. And so we looked at all those factors and compared them to what these treatments, and then they told us what would be the things that we wanted to look at. And again, there's a lot of, since we had already trimmed it down once, a lot of consistency, but one factor fell out, and that was whether there was a history of a previous infection in that shoulder, and that was the lowest ranking factor in all six treatment options. So that one we removed for the final round. Then we combined these factors into clinically meaningful scenarios. So unrealistic scenarios, which would still be paired, such as intrasuperscape if you have an intact subscapularis, we didn't think that that was realistic, so that one was dropped to try, because we also have to worry about survey fatigue. Everybody's busy, and you want to make sure that when they do these surveys that they're actually looking at them and take the time to evaluate it. So we came up with 60 different clinical scenarios, but then when you multiply the factors in treatment, there's tons of different options that are here, and then we ranked them. And the ranking for the final survey here was whether it was a preferred treatment, which could only be selected once. So if you had a clinical scenario that you said there's only one treatment, this is the best treatment, all the rest are not as good, then you could rank that as a preferred treatment. If you felt, well, these three are all acceptable, and all follow guidelines, and depending on the surgeon and the patient, they would be acceptable to do, then they were ranked as acceptable. But you could not have more than one preferred treatment per option. You could have all or none of the acceptables, and if you didn't have any, and then you could also say that one of the scenarios could have been not acceptable or contraindicated. So in this scenario, if it's a 22-year-old with a massive tear, which is probably not real, 35-year-old with a massive tear, and you wouldn't do a reverse on it. So that might be indicated as contraindicated or not acceptable treatment. And then you could put unsure, no opinion, but no one said that. So here's our answers, all right? So here's all the scenarios. And when you look at this, you say, wow, this is a really confusing thing. But if you look at patterns, you can see where things are going to line out. So here, where there's a lot of green, there's a lot of consensus that this treatment, which again was a reverse shoulder for this, there's a lot of agreement among all 72 participants. And then here, there's a lot of disagreement from all 72 participants. And here again, this is for younger patients for the reverse. So we could glean some data out of this and come up with answers. So we had 10 scenarios that reached 95% consensus as acceptable or preferred treatment. So you got to think about it. This is 72 guys who all think that they're shoulder specialists and 95% agree with it. So this is pretty strong consensus. Now this could be acceptable or preferred. Now all of these were reverses. Most of them were older than 70 years old with the presence of pseudoparesis. And they had an absent or irreparable subscapularis. So in that situation, everybody agreed that that was the thing to do. We had 20 scenarios that reached 90% consensus. And this is the other part of the Delphi process. No one says whether 95 is better than 90. So we wanted to look at where this line was going to draw and where we really could get some information that we could pass on to all the shoulder and elbow practitioners in the world to make a decision based on what these were. So now we've added in the 50 to 70-year-olds. Now the 50 to 70-year-olds, if they still had presence of pseudoparesis, and they—whoops, that went bad. Let me go back. So if they had presence of pseudoparesis, it really didn't matter whether there was a catalia. It could either be there or not. And demand also was—but it's also—I thought I had this one marked out, but absent or irreparable subscapularis. So when you have that scenario, even in a 50 to 70-year-old, then 90% consensus said it's at least acceptable and maybe the preferred treatment. We have 34 scenarios that reached 85% consensus as acceptable or preferred. So still, 85 is very, very high. And in this, now we've arthroscopic debridement or partial repair for mostly lower-demand patients. And that was kind of the key thing there. We had eight scenarios that reached an 82% consensus for preferred treatment. So these—this is really where the money is. So preferred treatment, that was the one solution that was checked off. Eighty-two percent agreed that this was the number one treatment. And again, these are for the reverses, older patients, pseudoparesis, and irreparable cuffs. So that thing you can really hang your hat on. We also had 80—or eight scenarios that reached an 80% consensus as not being acceptable. And this was very, very interesting. So as you'd expect, reverse shoulders, someone under 50, has an intact subscapularis, doesn't have pseudoparesis, we're not going to do a reverse on that patient. And those are the scenarios where you're going to think about the other options, the patches and the grafts and the different things. Interestingly, superior capsule reconstruction was also contraindicated in those patients that were—that reverse was the acceptable preferred treatment. So older patients, irreparable cuff, presence of pseudoparesis, and or dynamic instability. So where do we have consensus? Well, it's a preferred treatment. Eight scenarios had 82% consensus. They all revolved to reverse with the presence of pseudoparesis. Ten scenarios with 95% consensus for reverse with the presence of pseudoparesis. And then it went down to those other scenarios, which are all going to be published and you can look them up. There is also consensus is what's not acceptable and what's contraindicated. And again, those are four scenarios against SCRs in patients that are older, over 70, where a reverse is a much better solution. And three scenarios against reverse in younger patients where repair and grafts and all the other options that we have is a better solution. So the strength of the study, number one, the Delphic progress is very rigorous and it's a recognized methodology across multiple industries and academic platforms. We have an established group of specialists within a near circle. We identified specific factors that had the most influence on the treatment. We found consensus on certain clinical scenarios, but also there's a wide range of things that there wasn't consensus. So when you get to the people that are in the middle, the people between the 50 and 70 years old who have massive tears, we think that you need to evaluate those patients and you're going to make those decisions either preoperatively based on their MRIs and their activities and what their demands are, or you're going to do it intraoperatively based on what you can do when you try to do your repairs. But you're not going to just hang your hat and say, this is what I'm going to do. And these results can serve as guidelines for treatments for patients for the irreparable massive rotator cuff tears. And again, the manuscript's accepted. We're also working on an app that we're going to have that's going to be a tool so that if you have a patient and you say, well, you know, I want to see what everybody said on this one, you can punch in their clinical scenario and it will give you the results from this near circle consensus study. So our weaknesses, number one, we didn't account for patient preferences, unique situations that might affect their treatment decisions. And there's no established level for agreement for consensus based on this Delphi panel. So it's very throughout. You're really just trying to statistically decide where that's going to lie. And then with that, we really have a disclaimer. So with these limitations in mind, because a lot of people were concerned about litigation based on this, that someone's going to get sued and say, well, the near circle said to do this. And so we have this in the paper also that we use clinical social patient preferences to make decisions regarding surgery, and this has to be established between the patient and the provider. So what do I do? So in a younger patient, I do what the near circle says. So I'm not going to do reverse. I'm going to do everything I can to repair, partial repair, biceps, tenodesis, patch, graft, do everything I can to buy this guy some more time or a gal till they either just do well and we have those patients, or if I buy them 15 more years until they get their reverse, I think we've all done a service to that patient, and then their reverse is probably going to last their lifetime. But I get a little worried, and I do a lot of reverses, but when patients get in their 50s and 40s and the under. So in an older patient, so an ideal scenario, again, is a younger patient, intact, irreparable subscapularis, I think I can do a partial repair or some type of procedure that's going to help them out a lot, especially if they don't have pseudoparesis and they have low-grade atrophy. Older patients, again, the obvious ones are the ones who are over 70 and don't have subscapularis. You're just going to do the reverse. The reverse does so much better for those patients. So my ideal scenario for that patient is large tear revision, irreparable subscap, pseudoparesis, atrophy, and over 65 years old. Now there's another study just published in 2019 out of Rush, and they looked at their management of irreparable rotator cuff repairs, and actually it's very similar to what we found out as well. So they recommended reverses for high-grade atrophy, arthritis, we didn't want to bring that in on this one, but certainly at any stage in this scenario, you get arthritis and that's going to push you towards a reverse over doing any of these other things. And then use other options for younger patients. And functionality, I think, has been shown a couple of times, that sports after hemi and the cautions of reverses that came out 10 to 15 years ago about you shouldn't be aggressive with these things, I think have really been put to rest, and my patients do just as well. And that's really what I found. When I compare my anatomic shoulder arthroplasty to reverses, I get faster recovery, equal level of return to golf, tennis, and swimming, and really no radiographic failures for primary reverses at 12 years, except for trauma and multiple surgery-type patients. And I think it's a very reproducible procedure. I tend to use a 135-degree neck shaft angle and a little bit of lateralization. I think you prevent all the complications of notching, you get better range of motion and function, and I think there's a lot of that trend going on now as almost all companies now have this option. I think rehabilitation is really important. So I put the emphasis on the patient's role in their recovery. I make it their responsibility. I have a very detailed home exercise program that is available. We have videos on our website. The patients refer to them, and then we see them monthly. And it's doing all simple stuff that they can do. So they start off with doing either table slides or chair slides, and have all these videos that they can do. So we start them off on TheraBand. But these are all exercises that they can do in their home, and it's not very complicated. And then when people get to the three- to four-month mark, if they're having trouble doing things. So this guy is two months out from his surgery, and he's already doing, this is a whole wall slide progression where they use the wall to get up there, and then we'll turn them, and then they'll do eccentric lowering, which also helps to strengthen it. So it's a five-by-five protocol we give them. I want them doing their exercises for less than five minutes, five times a day. Oftentimes people think more therapy is better, and they start doing too much, and that's really when they get themselves in trouble. And we get amazing results. So young people, older people, these are all with reverse shoulders, and nearly full range of motion on many of them. This guy's returned to a five handicap at golf. This guy, in fact, I just saw him this week for his other shoulder. He's nine years out and still lifting weights, doing planks. This guy's five years out doing pushups. He wasn't tired, so maybe video him from the other side. This guy's swimming, and so everybody knows you're going to do breaststroke, but here he goes doing freestyle overhand crawl, and I think with the proper rehab, you can get this type of function for all these reverses. This guy's six months post-op showing us his Bowflex routine, and he's admonishing my patients that they need to do more. This guy's had both reverses done. He's playing basketball and throwing footballs. So I think being concerned about doing a reverse and not allowing patients to go back to function is really not. So what about this guy? So this is the guy we started off with. He couldn't raise his arm, and he had a bad tear. Here he is six months later. He's doing a little bit better. He's still struggling, but at a year, he's got new clothes, got better flow in his hair. He's got new goatee. This guy is feeling really, really good. Thank you very much. Thank you.

reverse arthroplasty

massive irreparable rotator cuff tears

treatment options

patient factors

consensus

rehabilitation