Least expensive, here you go. We're back to not having a long explanation with your partners. We're going to talk about the biceps autograph. This may be the first of these. Where is the clicker? Thank you. And cuff healing problems. We've all been through this. This is a lot of times with revision surgery, 61-year-old female, left shoulder pain and weakness, non-operative treatment failed, previous right shoulder surgery with success. The range of motion here is somewhat compromised, it's not because it's stiff, it's passive motion is good, active motion is bad, impingement pain is the issue. Some loss of function as well, loss of sleep. This is the MRI. You look at the umbral head. Don't get fooled about superior migration on MRIs, they're supplying patients. It's much more important when it's an upright patient. Also look at the biceps, although fluid around the biceps may or may not indicate disease in the biceps itself, but we're hopeful we got a biceps because that's the reason we did this case. Whoa. Next case. Yeah. Yeah, I don't have any mouse. Can you see if that video will run? As we get into the case a little bit, you'll see it's a pretty good size full thickness retracted supraspinatus tear, but as it goes back into the infraspinatus, I'll go to the next slide if you can't do it, but it'd be nice if they saw the pathology, the infraspinatus has a significant delamination with some deep fibers intact and your treatment options we've gone through. That's what we're talking about this morning. This is a little bit what we may do, and again, this is what I was trying to allude to with one of the questions earlier about getting the cables down, meaning the anterior part of the cuff. In this case, the posterior part of the cuff. That's a posterior anchor in the greater tuberosity, and that's going to take care of the delaminations of the infraspinatus. Lateral view, I'm going to come in with a sort of a retrieving instrument, get through both of the layers of the delamination so I can close that down. Anteriorly, I'm going to use an anchor, and I'm going to do a combination of a mattress suture, simple suture, two separate sutures to create a better fixation of the anterior margin of this rotator cuff tear. I'm not going to try to cover the footprint. The anchor is really right next to the articular surface, and you can see with the releases you heard about, particularly the coracoumeral release anteriorly, you can get some mobility of this anterior tissue. It lays down anteriorly, but you're left with this defect between the anterior and the posterior margins. Sometimes you can do a little bit of a side-to-side stitch as done here, just like a margin convergence between the posterior margin of the supraspinatus, but the part that's almost always deficient in these bigger cases is your supraspinatus. So now I'm back in the shoulder. I'm going to put a stitch through the long head of the biceps. I open up the interval lateral to the coracochromial ligament, and I release the biceps off of the labrum. I retrieve it in the subacromial space with my anterior anchor stitch that's right at the anterior cable. As I tie this down, it will reinforce and cover over the anterior margin of the tear and leave me a stump of tissue that then can get incorporated into the infraspinatus or additional anchor to the tuberosity. So this is my extension of my supraspinatus tissue as I'm bringing it over the top. This is coming out the back. I can use the stitches. And what I'm going to do is basically use an inexpensive 15-minute addition to the operation of using the biceps to complete the repair of what I thought would have been a somewhat difficult case. I want you to pay attention to that anterior margin. That's the posterior view of your biceps tendon. But this is the one I want you to pay attention to. As you look from a lateral view, you can see what it's doing to the anterior margin of your supraspinatus, holding it down almost as if it was an anchor, and you've got your defect closed. Inexpensive. Thanks, Bob. Hey, Jeff. Did you release it off the glenoid? Off the glenoid. Sorry. When I put the stitch into it, I then released it so I could pull it out through the rotator interval. So I do it the other way. I release it distally, leave it attached to the glenoid. And it becomes a biceps SCR. Okay. That's not how you do it? On some cases, where I have no supraspinatus, I use it as an SCR. And there are, I think, and you might comment, because you know the literature best, there are some indications that simply fixing the anterior cable in an SCR situation where you think that's what you need to do, just restoring that anterior cable may be all you need, and that you don't have to cover the defect. That's Denard's study, right? So they reversed pseudoparalysis with just fixing that anterior cable. Think about that. It's a much easier operation. All right. We're going to try to get through these last two real quick, because we just want to touch on this. So this is a 60-year-old...

shoulder injuries

treatment options

impingement pain

MRI

range of motion