We're going to put a panel up here, and these are actually going to be cases, so the didactic portion will hopefully bring out as we start bringing up questions from the audience, questions from me, questions from our moderator. Bioinductive patches is interesting. A lot of things you're learning about and are going to hear about this morning are really scaffolds and whether you look at them as biologically active or really like putting a prosthesis in the shoulder. I don't mean literally the metallic ball in the glenoid, but just putting a spacer trying to recreate the anatomy of the humeral head facing the glenoid. This is a little bit different. This is trying to say to the trip, the biology to try to help us heal, I've had a number of relationships that should not have a major role in what we're going to talk about today. So when you look at a partial... With that many relationships, how could you not have? Look at that. When you look at a partial thickness, oh, this is even better for my arthritic neck. So if you look at a partial thickness tear, this is something that's a little bit different. You have something, you know, your glass half full, your glass half empty. So the question really is, how do you handle this? And there's been an argument along the way of whether you should just cut the whole tendon and create a full thickness tear, or you should deal with just the part that's damaged. And then the question is the part that's intact. So it goes on and on, and we debate about this, but ideally, you think about it, there's a part of the tendon, and it's not a traumatic tear, but a degenerative tear. You're in a little bit of trouble trying to bring that piece of tissue back to a tuberosity and expect it to be equal tension throughout all the layers of the rotator cuff. So you end up what they call tension mismatch. And as a result, many times when we fix partial tears, regardless of your technique, it's not uncommon to deal with problems with patient stiffness after surgery. And most of the time, that's because of this mismatch in layers of tendon. Also, the disease extends medial to the tuberosity. So if you're going to grab a tendon that's medial to the tuberosity, and even if you medialize the footprint, you can certainly have difficulty. Now a 69-year-old female, and this is 69 physiologically, 49, playing competitive tennis, excuse me. Tennis. Tennis. Tennis, yeah. Tennis from playing tennis. Yeah, tennis for tennis. At 69 years old, left-hand dominant competitive player, and she's symptomatic for greater than nine months. She went through conservative treatment. What's noteworthy is she did have a full thickness right shoulder repair, probably about six or seven years prior to this case being reported. And now she's unable to compete with her dominant arm in tennis. Her physical examination, she has a relatively normal range of motion, slightly less at the terminal ranges. She has positive impingement. Interesting, she has painful apprehension sign, which means that she's not worried about her shoulder coming out. It's just painful in the provocative position like a service in tennis. And if you push on her head, it tends to relieve some of this, so you start thinking about maybe internal impingement as well as possibly part of the cause to add to her dilemma, again, in spite of her age. Her imaging studies, if you look at it, you see the pathology along the undersurface of the supraspinatus tendon. In some places, it looks like it's approaching a full thickness tear as you get probably back towards the supraspinatus-infraspinatus junction. And you can see on the bottom picture that you're starting to get some disease that actually migrates medially to the tendon insertion, really under the muscle. You're getting some ganglionic cysts and fluid formations from an intertendinous delamination. This is what the tendon tear would look like just to help us diagnostically for the conversation. You can see it's, again, as you might imagine, a frayed tendon. Sometimes the tendon are medialized as it's pushed away from the articular surface. She has really pristine for 69 and all these years of tennis. Her articular surface is normal, but you have to appreciate she still has the healing potential of a 69-year-old person. Very few morbidities, obviously. And so here we are. We're just kind of showing you a little bit of a debridement and trying to exhibit the footprint. And again, this tear extends supraspinatus, but all the way back into the infraspinatus, again, possibly duplicating some interarticular impingement as opposed to an external impingement. You get up on the top of the rotator cuff and the tendon looks fairly normal. So you're basing a lot of your study on the exposed footprint. What's the degree of exposed footprint, meaning getting a percentage of a tear? And we're going to say that this is probably about, in some cases, as little as 40 or 50%, but as great as 80% in places. So as we look at this, I'm going to just open this up a little bit. Maybe the panel could give us a little bit of their impressions. But there's some options. And really, this is a degenerative lesion that's been traumatically worsened because of her sport. She didn't have a single event that she put her arm up and all of a sudden fell down and hyperextended. Where would we go with this? 69 years old, competitive tennis. She anticipates going back to a competitive career. She travels, actually, to play tennis. Where would we go? And I'll go right down the line. Mark, give any of the first impressions on what you would do with this person, dominant side. Yeah. So as I look at it, particularly more posterior, and you were saying she has the positive apprehension test just from a pain point of view, that's where the cuff got a little bit worse when you're looking at the MRI. I worry about the healing potential at 69. When you look at her trying to get healing of her own tissues, I personally would probably lean towards taking that down and repairing it just based on her age and her activity level. The fact that she is a competitive tennis player would probably push me away from that a little. Let me ask you, just before I keep going down, if you did take it down and put it back, would you put the anchor near the articular margin or would you put it laterally? Because she's kind of developed that groove where she may have a little bit of exposed footprint as just an adaptation to her sport. Yeah. More posteriorly where you have truly the bare area, I would tend to come back off the articular surface a little bit, but in the central portion right where the worst part of that cuff tear was, I'd put it just off the articular margin. JT, give me your thoughts on this case. I would go about it totally differently. That was a really angry shoulder you showed us, and this is a competitive tennis player, and if she's 69 and you take that down and repair it, you're hoping that's going to not re-tear, and it's probably, you're on the losing end of the odds on that. I'm not touching that cuff other than to debride it like you did. I'd probably take her biceps, a little red in that, and probably has issues with apprehension, with a positive pain sign there. Going to leave the cuff where it is, debride it, and give her a shot in that regard because she's an active tennis player. When you say take the biceps, I'm assuming either a tenotomy, tenodesis, something along those lines. Yeah, tenodesis. Do you think that, let's just, one little stretch going outside this ICL, do you think that that biceps may be actually a restraint to her abduction, external rotation, and therefore she's going to go further when you take that biceps, which means her internal impingement findings may actually worsen without the biceps in there? Yeah, so there is some evidence that we can be tight in that position, but in a 69-year-old, we're not talking about a 20-year-old baseball pitcher, that biceps is going to go the way of the dodo as fast as I can make it. It's going to relieve her pain. She's going to get back to tennis. It's not going to be a problem. All right, Rick, we're in the sixth decade, you and I. Give me your thoughts. No, to me, the problem here is this is a delaminated tear, and that inferior lamina is retracted immediately. That's the problem. And so this is a 69-year-old, healing potential is not great. I take it down, and I then put a separate stitch through the inferior lamina and make sure that comes to the articular margin. I wouldn't do a double row. It's going to be tough anyway because that, it's retracted. So if you really want to get a full thickness repair, you got to get that inferior lamina over. If you don't, and you just kind of incorporate it, but you don't really incorporate it into the bone, I think they have persistent problems. This would be a takedown repair. It'd be very gentle, but it would be including the inferior lamina. And I'd hang crape saying that many people get it over. I thought you were just going to put that collagen patch on top. I mean, just tell us. For you, JT, I wouldn't. Let me go back to you on this one. For an athlete, I'd do different. So technically, are we talking about a transtendent operation? Takedown. So you're taking it down, and you're getting the medial edge back. I'm going to just tell you that older patients with retracted chronic tears where we have tissue loss, they have the worst results with a posture repair. What are you quoting her in terms of her healing rate? What would I tell her? I'd say 69. If she's healthy, no comorbidities, and I can get this back, I'd tell her about 8, 85%. And if I were really concerned that the more, you know, I need something, I'd augment it if I was really concerned about repair, or I'd put a bioinductive scaffold on. But to me, this is a takedown, repair, really focus on getting that inferior lamina back. Okay, audience. What about the biceps? Are you taking her biceps automatically? I do not automatically take the biceps. But in this case here, I'll be honest with you, I didn't see it as much. I saw some inflammation. But if I go in there and I think that it's part of the problem, I'll take it down. But I'm not an aggressive biceps person unless I think there's real pathology there. So if the intraarticular portion of the biceps, I know that's not where we are, but if it looks okay, how do you decide then? I think I almost have to make that decision before I get there, right? If she's tender in her groove, and she's got, you know, positive speeds test, then I'm going to take it. But, you know, I think if you're looking at just what you see intraarticulately, you're going to be fooled. Well, you can't. What I would tell you is that for me, when people have real biceps problems, they tell you that it goes down the front of their arm, I mean, it follows the biceps. Everyone when I mash on their biceps has pain. I just don't find biceps tenderness a really, you know, preemptive thing that I can follow. I'll help the panel a little bit there. She really didn't have speeds test. She didn't have a biceps groove pain. Leave it alone. She didn't have distal radiculopathy. She had deltoid symptoms at the deltoid insertion, which, as you know, is so common for just generalized symptoms, not specific. I would leave it alone. How many in the audience here would do arthroscopic debridement and call it a day? I got John Conway. I got John Conway back there, yes, sir. And John Conway has learned the other way, that if you start taking some of these posterior tears down, meaning the internal impingement, you can find yourself short of success in this thing. You know, when you look in the throwing shoulder literature, there are two papers that stand out as ultimately successful. One by Andrews with debridement in the throwing shoulder, and one by John Conway with the paint lesion there where he repaired him. So we went and talked to him about it and said, what do you do? He goes, I abandoned that years ago. So there you go. So the repair part. And I did a fellowship with Andrews, and after a number of months, I figured out what he was telling me. He really said, you're dealing with an athlete in a period of their time. It's not necessarily their lifetime operation. So he's trying to reduce the splinter in the finger pain, and maybe is going to plan to have to come back another day. Well, Jeff, I want to point out, and this is really, really important, you know, John takes care of very high level baseball players, JT does. I'm going to tell you that tennis players, volleyball players are not baseball players. A third baseman is not a pitcher. So we have to keep in mind who we're talking about. So internal impingement in a 69-year-old tennis player, I'm not worried about that being a problem down the road. And I've taken care of plenty of these and fixed them, and they get back. It takes longer, it's not easy, but they come back. A baseball player is a completely different thing. Swinging a racket is very different than finding the slot for a slider. And then just to get to that point, I'm going to grab your question, but just to get to that point, to get to that external rotation in an overhead throwing is different than a tennis serve and probably different than volleyball. And some of the rehab with regaining their crushed chest, internal rotation, posterior capsule stretches is an important part of the non-operative program. Sir? Yeah, adhesive capsulitis. So you know, her interval tissue was not inflamed. She didn't have a reduced inferior pouch. She had none of the intraoperative findings to suggest we're talking about adhesive capsulitis. I think a painful shoulder, this was more subjective. I did not go through the process of doing an interarticular injection, but I suspect she'd have an identical exam in our two shoulders. So I don't think I could go down the road of adhesive capsulitis. Now some reactive stiffness, I think I would put this into that category a little bit. But your point's well taken. A stiff shoulder, you probably don't want to go with much. Yes, sir? Yes, I would. If I really thought that there was a range of motion, to your question and to your question, if I personally thought that the patient had a significant change in their physical exam, I would go after that initially before I brought her to the operating room. Then the question is, if you do bring her to the operating room, do you incorporate some type of capsulotomy and leave the damaged tendon alone? Because all of us will admit here, the risk of making this shoulder tight and add to stiffness is certainly real no matter what we talk about as soon as anchors and sutures are going into the shoulder, even with a takedown. It may be that we're going to be on top of our physical therapist, communication with the patient, that type of thing. But we certainly are at risk for some degree of stiffness, which would maybe be critical to an overhead throwing athlete, maybe not quite as critical to a tennis player. They could have a little bit of a loss of external rotation, but nothing significant. I got to reveal the cards, otherwise we don't get to the next case. So here we go. We're getting into the subacromial space. You got a little bit of an introduction. Like I said, Rick did a lot with some of these things. But here we are. There's the biceps. There is a little bit synovial tissue around it. And we're basically doing just some preparation work. Now I'm trying to find my landmarks on my subacromial space. I want to be over the damaged area, because the bursal tissue is really very pristine, actually. And I could lateralize a pin, a guide pin, just to prevent me from overextending the position of my graft. Anteriorly, those needles are identifying the leading edge of the supraspinatus. So I'm not going to go over the rotator interval. I got the needles in front. I got the needle laterally. So I could position this graft. And then once the graft comes in through a lateral portal, I could put in absorbable staples. And some people felt that these PDS composite staples could potentially actually create its own inflammation in the shoulder. So we've gone to putting perhaps less staples in some of these shoulders than we did initially. But this is about a five-year-old case. So we have some follow-up on it. When you get laterally over the greater tuberosity, you're no longer looking at the absorbable staples, but you're actually putting little drill holes in the greater tuberosity. Some feel that this may be what stimulates the articular-sided cuff repair and response. And we put peak-type staples in there. And so our patch basically sits right on top. And we did not try to do anything with the medial delamination. We didn't try to do anything with lateralizing tendon. If you look inside afterwards, it's interesting. Obviously, you should still have a pasta-type tear. But the tendon is more robust with the tissue sitting on top, even though it's not mechanically strong at all. Post-operatively, you do things differently with these pasta-type tears. And again, we're always worried about stiffness. So we're going to keep them in the sling a little less. And I learned this from Des Boca. He actually let them come out of the sling almost within the first week. I don't know that I would go with those suggestions. But we go to early range of motion just to avoid the potential for an adhesion or adhesive capsulitis reactive to this. And we start our active motion. And we actually go to strengthening a little bit earlier, too. Because don't forget, we have still intact tendon next to deficient tendon. And about week 12, which is about three months into it, she starts ball striking ground strokes. Whether this is the way you'd like to take care of it is just a managed how she was taking care of it. I'd like to just briefly touch on some literature. Teddy Schlegel and others, even on the panel here, have spoken about it. 33 patients, multi-sentence study. And they realized that they were doing post-operative MRIs, two millimeters of tendon thickness at the end of it all, with the majority of having complete healing, some of them having just improvement, one patient who was non-compliant or re-tear. One of the guys who really started this all off in Australia was Des Boca. And he looked at basically MRI follow-ups two years and recently reported that there was both clinical improvement and imaging improvement in spite of the accelerated rehab. And he had fewer post-operative restrictions. Arnosky is the first one to look at basically putting a needle biopsy in with the help of the surgeons following his name. And basically at three months, the collagen formation was already occurring at the articular margin and he called this organized fibroblasts. So they were better, it was a scarring response that filled in the footprint. But nevertheless, he felt that it was a better quality than typical fibroblastic response. And by six months, this patch was gone. And Rick and JJ Ryu, if you want to see some more detailed pictures, because Rick has a great way of getting pre- and post-operative MRIs, if you want to see a case, go to Orthoscopic Techniques and he'll go and show you a few of how at least he presents this case. So if I can, this bioinductive collagen, at least in this lady, was significant. We avoided the pre- you know, she had some pre-operative stiffness as was mentioned in the back. She did have partial thickness tears with intertendinous extension. Perhaps the most easy to understand and comprehend and buy into is these bursal tears that you're going to now try to pull over. Maybe you shouldn't try to do bursal tears. Maybe the patch makes more sense than trying to lateralize a retracted bursal side tear. But even in this articular environment, we're finding that we can do something to the thickness of the tissue, which going back to the biomechanical slide that Rick Ryu pointed, if you make your bursal tissue thicker, it unloads the articular side and gives this an opportunity to lay down some collagen. So comments before I pass the mic to the next? Go ahead. Just, you know, we saw a presentation from Dr. Savoy yesterday on the podium about not using the PEEK staples laterally. What are your thoughts about that? I'm pretty comfortable with PEEK. I'm more concerned with the biologically active staples and there are a number of people who do develop synovitis. I think JT and I have had a couple of cases. One, I actually went back and I was nervous. It was about six, seven years ago and I took the graft out thinking it was an infection. I just didn't know whether it was P. acnes or not. It turned out it was sterile. He was smart enough to say, I'm going to wash it out and see if I could survive. And I think that there are a number of patients that can get synovitis, whether it's to the graft, whether it's to the staples, whether it's to the operation. Hang in there. It's not necessarily a post-op infection. Jeff's being humble. We were at a meeting and he had his usual busy schedule and he gets a phone call from the patient and there's a concern about it and he goes, I got to go home. So it's like a Thursday. He jumps on a plane, does the operation, and Friday morning returns to give the rest of his talks after the case was done. Patient did very well. New York City cop, if I remember correctly. That's right. Unbelievable. A practical question, how do you get this thing paid for? And you said she's 69, which makes her Medicare age, which means you're now having to make that decision. And that to me is one of the things is if you're planning to do a takedown, you know, Rick and I are doing this case in the surgery center. No question. Now you're deciding what you're going to do and you're going to have to now do this at the hospital potentially because you don't know whether you're going to do it or not. And how do you get this thing paid for at $3,600? Yeah. So you, at least in the workman's comp motor vehicle world, you kind of talk about your implants before the surgery. You get to the insurance company, you get to Medicare and there's no one to talk to. You know, Washington is empty. So the bottom line is if you're going to do this, you better be pretty convinced it's the best way to go for this patient, therefore avoiding a new surgery. But your partners have to be somewhat gentle with you and you better not overuse your favors with your partners because you're probably paying for this graft and that's, that's a real number. One of the things I love about your approach here is I think the 69 year old that you're going to put out for seven to nine months after a rotator cuff repair has a really hard time coming back. And the worst case thing happens here and the patient doesn't do well, you can always go back in and do that big takedown and big cuff repair and hope. But at least in this particular case, she's getting back to the tennis courts very quickly with a very high success rate and if she fails it, you've still got an option. So Jeff, a couple of these ones is my biggest complication in this operation has been at least a capsulitis. And I would tell you, be very careful about the leading edge of your graft coming into the rotator interval. And so I've overlapped a little bit by being sloppy. And if you get close to the interval and start to scar down, they get stiff. And I've had five in the past hundred cases where they got pretty stiff and I'm pretty sure it's my technique. The other that's interesting is people actually feel better sooner when you add it on top of a rotator cuff. You know, Steve's, Steve's a, he's not a plant, he's my mentor, he was my chief resident when I was training. No, no. So Steve, let me see, we, we did, which shoulder did we do first? Right shoulder. We used an implant. Second side was a little bit uglier. We fixed it, put the implant on. Can you tell us what, what happened? This is anecdotal, obviously, but it was, we've seen this a lot. Yeah. So, uh, when I go way back, I had the honor of, again, operating on you. Desperation. And I don't know if it's had rotator cuff surgery, but it's a rather painful operation. And I've had the honor of having my back operated, several knee surgeries, shoulder surgery takes the cake. No question about it. With Ryu. Yeah. Yeah. With Ryu. He was a... Surgery with Ryu. I'm, I'm, I'm just so impressed you're here today. He now, he now uses opioids. Two years later, and a little bit bigger care, he wanted to use the Regeneron on it. And that all went well. And Rick followed up with me. Well, actually, I think I called you about four or five days later. And I go, Rick, this is a totally different operation. Did you do something different? He went to an L.C. course. And the difference was, you have to swallow for knee surgery, and it's a very often period of course. But typically, a rotator cuff will stay angry. You'll have difficulty sleeping for two to three weeks. That's pretty average, at least for me. And within about a week, there's dramatic pain reduction. Totally different style. So, I thought it was remarkably different. I got a MRI on my shoulder, which was just fantastic. I don't have that result at all. But my shoulders are great. And you, since you have, you're a perfect study with two shoulders done, do you have a favorite shoulder right now between the two? Did you feel that ultimately, it was an easier recovery, it sounds like. But at the end of the discussion, did you feel like one shoulder was better? Both are great. I think that one with the Regeneron patch is a little superior. Thank you. When we put this together, I thought the Regen10 patch, or the bioinductive patch, was going to take about six minutes. We're now halfway through our ICL, so we're going to move on.

bioinductive patches

shoulder injuries

partial thickness tears

collagen formation

surgery

rehabilitation