the website, and kind of a very similar case example. This is a 71-year-old who I see all day long in my office, so it's very similar to what Jeff presented. Some vague shoulder pain for several years, and then playing tennis. She suffered an accident six months previously and developed increased pain. She was pseudoparetic. She had 120 degrees of forward elevation and abduction, but she had good external and internal rotation. She was not stiff in terms of that. She had positive impingement signs, and she was markedly weak with forward elevation and external rotation testing, and she had failed anti-inflammatory. She had already had a cortisone injection elsewhere, and she's basically miserable. She can't sleep. She can't do what she wants to do, and we're in that same place, and here's her x-rays. There's a hint maybe that her head's moving up, probably a mod of two there, and a little bit challenging in terms of what we're gonna deal with, but then we get her MRI, which is really more concerning. Clearly, she's had issues for years, and she's obviously been well compensated until whatever happened six months ago. We're looking at her muscle there. What do you say, JT, a three? Probably two to three in terms of where we are, and on her coronal view, you see her head is up just a little bit, and so we're in this challenging situation. She's already had conservative care. We've already gone to physical therapy. She's already tried a cortisone shot, and she's just miserable, and you kind of start talking about the reverse question with her, and their eyes bug out of their house. I am not having a replacement. I can't do what I wanna do, and you're just not getting anywhere, so in this case, you got this big tear, acute on chronic, potentially high retear rate with at least a two-tendon tear, and we've got multivarate factorial risk factors that we touched on, chronicity, stiff tissue, patient over 70. Fortunately, she's not a smoker, and I see very few smokers in Southern California, but we still have poor healing that we have to take into account, and unlike the care that we saw from Dr. Abrams, this is a large tear, and so it undergoes this metaplasia where you have less healing potential, fewer blood vessels, fewer fibroblasts, and what are we gonna do? There's significant differences as we think about this, and we may need to help the healing in some way in terms of trying to decide how we're gonna deal with this two-tendon tear in an older, active individual. JT? Dominant or non-dominant? Dominant. Dominant arm. Chief complaint, pain or functional loss? Both. Yeah. Truly both. Yeah, so I think the idea that you're gonna get this cuff to repair or reheal, and I'm a big SCR believer in the right situation, but this is one that a reverse shoulder is a really good option in, and for me, just full disclosure, I don't ever repair the subscap, so it's my fastest rehab, so that patient goes back to activity at will. And so that question is raised with her, and I was like, look, this is probably a better operation for you. You're gonna get back quicker. She won't even hear about it. She won't do it. Yeah, won't even hear about it. Then you're stuck, right? So now you've got a situation, do you believe the muscle is good or bad? So for me, if there's muscle, there's hope. So if you conclude that this muscle is healable, then I think patch is in play. If the muscle's dead, then you've got only one choice, and that's a lower trap transfer. So we talked about some of the graft options that are out there. We talked about the Xenograft, and we talked about the IT band as an augmentation, and synthetics are certainly coming on board. For us, this is where we will use a lot of dermal allograft, and I think allograft has good results in the past. You can improve the biomechanical repair strength, which I think is really important, and it allows you to potentially close these residual defects. And I think it can potentially help you limit over-tensioning, where you're not trying to pull that tissue too far out to the side. The biomechanics on this are actually quite good. You can actually increase the strength of your rotator cuff repair under cyclical testing significantly by 30 to 40%. And in the paper that was done by Alan Barber and Joe Burns, one of my former partners, we got double the healing rate when we looked at the healing on the outcomes. And so if you can improve from 40% healing with a big tear like this to 85% healing, there's something to it. And if you look at the systematic reviews, there are good results that support the use of using a dermal allograft as an augmentation. So similar to what Dr. Abrams just showed us, there is some real value in that. So for me, what are my indications for it? I use it for revisions. I use it for these massive tears that are chronic but repairable, and what I call tears at risk. If it's retracted more than two centimeters, if they have chronic push traumatic changes, anything that has more advanced cutaliate changes and some atrophy, then I'm going to think about adding this graft. And, you know, because I have the ability to kind of add strength at that place. So here's what we're looking at, and here's what we have, and you can kind of pull it. It was reasonably mobile, but I decided to kind of do more of a margin convergence and get it closed. And then here's where we're bringing in the dermal graft. So this is very different, much harder operation in terms of what we're doing here. But then I go ahead and sew it to the native rotator cuff, and then I come over the top laterally. And then if you go inside the joint, you know, we're able to go ahead and get that rotator cuff back, and using the dermal allograft as an augmentation device, we're able to potentially get some better outcome. Gentlemen, any comments? Yeah, you know, you sometimes wonder when do you put the graft, the allograft under the cuff? And when do you, as you're going to hear in a separate lecture, or when do you put it as an augmentation on top? I like what you've done where you say, I could get the graft back to, I could get the tendon back to the tuberosity, but I can't do any kind of footprint coverage with it. It's already compromised tissue. And so by getting it as close as you can, then I'll use an onlay to go over the, just like a hair extension, right over the top of the graft to the lateral margin of the tuberosity. I think that's a good indication for that graft as opposed to underneath it when you can't even get your tissue back to your tuberosity. So Dr. Rita likes to sandwich it, right? I can on equation, but you know, there's a very interesting paper route that's being presented here, and he's one of your great fellows, Ivan Wong, looking at maximum attempt at repair versus interposition. Interposition by landslide was much more successful than a maximal repair approach to these types of tears. How do you feel about that? Because you have data on both sides. You just presented a very, you just published a very nice series, single row, great results, the SCOE technique, great 90% success rate. Then you also presented your interposition results, which are phenomenal as well. So in this situation, why not interposition? So if you go back to where I just pulled on that cuff, when I can get that cuff at least three quarters of the way back to the humeral head without tension, and I know I can do some type of margin convergence, in those cases, I find that it's better, you know, level five evidence to go ahead and put the cuff tissue up on top. Because if I'm using the graft, and I do a lot of interpositions, I find that it may not get me the forced couples back as well. I think this may restore their forced couples a little bit better, and I functionally feel a little bit better about them. I also let them go a little bit quicker. Yeah, I think it really brings up the concept of augmentation. Mahat has also shown that, for those of us that are SCR believers, right? In the patients where you can get it repaired, but you're looking at it and going, eh, I just don't love it, the interposition and the augmentation has definitely shown an increase in healing rates, increase in functional outcomes. So if you're a cuff surgeon, I think the idea of having something in your quiver to be able to add to that cuff is a really, really strong. One last thing. This won't be the last time you hear this comment this morning. It might even come from the other speakers if they buy into it. If you can improve the acromial humeral head distance, meaning depress the humeral head because there's some tissue now located between the acromion and the humeral head, you're gonna improve even the tendons that have not been torn. In other words, reduce the boutonniere deformity of the humeral head subluxing up into the defect. Let me push you on that a little bit. Let me push all you guys on that. If we talk about reducing that or pushing that as a humeral head depressor, at the end of the day, is that existentially the whole point of the cuff? In other words, if we can do that, and this gets to the balloon question that I think you're gonna present on later, is that all we need to do in your head? No, the problem with the balloon is it goes away. So I'm looking for something that creates a thicker sandwich. I put the bioinductive graft on top for two extra millimeters. Here's another option to putting something on top of your biologic. So if you believe that, then forget SCR, forget cuff interposition, forget anything. Let's just stick a sandwich of human dermal allograft on the humeral head and call it a day. Why would we ever repair a cuff? Well, I think the fact that you're increasing the functional activities of your subscapularis and your infraspinatus tendons, they do have a dynamic active effect. These are already a sick muscle. So we're not ready to call the humeral head depression the be-all and end-all. No, I think part of it is a static effect and not a dynamic effect. I think the dynamic effect- It's a single center of rotation. So bringing the head down in of itself isn't the goal. The goal is you get one single center of rotation so your bigger muscles can do their job. So it's kind of like when it slides up and down, your big external muscles just aren't effective. But if you can get one single center of rotation by bringing the head down, they're much more effective. Isn't that what we're trying to do? Plus also, if you think about the SCR, where we're seeing the failures from Ms. Ryan's work is all on the glenoid side, right? And so the nice thing I think about interposition or even coming up on top is you're preserving the function of that muscle that remains, hopefully, right? Because you're still making that muscle work as opposed to a true SCR. And you've convinced me of that. So I'm doing much more interposition now than I am SCR because if there's any muscle that's there that can be utilized, and Mark was the one that sort of made me rethink this, I mean, it may not be quite as mechanically efficient as an SCR, but you have living tissue and you have an opportunity what I think might be a long-term solution because I'm not sure my SCRs are a long-term solution. But remember, SCR doesn't take away your ability to do an interposition. You can throw your SCR on and still attach stitches distal to the glenoid, and then you create both an SCR and an interposition, and you get the best of both worlds. Why wouldn't you do that? Because I don't like, well, I don't like anchoring my graft to the cuff. In other words, it's adynamic. You're tethering it. Nope, not as long as you go with your stitches beyond the glenoid. If you bring your glenoid stitches up and do it, then you've tinnitused your cuff, you're right. But if you take those stitches beyond where you do that, then when the muscle fires, whatever you got left, it goes right into the patch and right onto the humeral head. Plus, you've got both. Well, I'll have to see your technique on it because I've looked at it. That was Rick's way of saying, I think you're full of shit, by the way. JT, let's go ahead and do your case. There are some tables down front. They say special services, but you guys can certainly grab these tables down front if you want to sit. I don't have a social service. Kevin, what do you think? I don't know. We can keep going. If you have questions, we would really like to have you join in and ask questions. This is confusing, I think, for all of us. And you can see right here that almost none of us have agreed on how we would treat the patient. So I think most of you in the room probably feel the same way. Like, you know, this is ridiculous. These four guys can't figure anything out. And so I think you're not alone because I think we have very different approaches to this. And this is a wild west. You know, the old saying is, just because I'm in the wilderness doesn't mean I'm lost. So, you know, we're somewhere, we're out there, but I think we have reasons for why we're out there. We just have different reasons. And I'm sure all of you have the same thing in your practices and perhaps a course like this just helps you understand maybe some of the conflicts you've been feeling and how they're very common among all of us. So, you know, we hope you'll ask questions because this is a tough area. One more question. How many of you are in the movement, participation? And I think this came back in the course, Franco's course, and it's really popular. A lot of guys are using it. And to your comment, Dr. Tovey, I don't think it's temporary, but the thought was it's a way of rehabbing your muscles by depressing your head and getting all these muscles that haven't worked for a long time to balance again, realizing that that spacer is effective in no way. Yeah, that's the theory. There are a number of guys that have abandoned it in Europe that have had longer term results. And here's the issue, right? So we have done an awful job of distinguishing between the rotator cuff pathology that is painful and the rotator cuff that is absolutely dysfunctional. So if you have a patient who says, I can't do my shoulder, and you inject them and they go like this temporarily, and they're a massive cuff, stick a balloon in them. Because if you take away their pain, which the balloon has been shown to do, magically they're there and you go, look, I cured pseudoparalysis. No, you didn't, you cured pain. You take a patient who has no pain and get pseudoparalysis like this, that balloon ain't helping, sorry. And the folks in Europe that have done this Ravenscroft and a couple of the Italians, et cetera, they would agree with this. So this isn't just me speaking out of church. So I think it's really critical. That's why we talk about this. Is it pain or is it function? Somebody who says, ow, you can do anything you want. Biceps release, Walsh and Boileau have both shown that in separate studies. You can use the balloon, you can do rehab. That's been shown. In fact, the best study in the literature on pseudoparalysis is rehab by Ofer Levy. And he cured all of them. We did a systematic review on this a few years ago, and there were 18 different studies with six different approaches and they all worked. Everybody said, oh, we cured pseudoparalysis. But they defined pseudoparalysis as less than 90. So here's the point. If you took a patient from 88 and after surgery, you took them to 92, that was curing pseudoparalysis. And you say, no, nobody published that in the literature. The hell, yeah, they did. We all did. And so that's the problem with that. So we have to get better about defining our terms. I hear Hawk in the back of my head here, Jeff, about saying, look, is this painful or is this? So that's why I think that's such an important discussion and why SCR has such variable results in the literature. Because the truth is, is that if you've got a patient with pain, SCR is a tremendous procedure. But if you've got a patient who's got functional loss and dead muscle, that muscle ain't coming back. Sorry. Anyway.

shoulder pain

rotator cuff tear

impingement signs

reverse shoulder replacement

dermal allograft