Good morning, and thank you for being here, and my thanks to Dr. Gellman for inviting me and being part of this really outstanding faculty. It's a real honor for me. You know, this is going to be a brief overview, and we need to have the language down because we're talking about a lot of different things, so this kind of becomes important as we talk about augmentation, interposition, you know, what are we talking about. So this is my disclosure through the academy. And if we talk about massive cuff tears, we could talk about, you know, the different things that we can do. But today, we'll look at primary repair and how that can be supplemented. And we can talk about a bioinductive scaffold that has zero strength but in-growth properties, dermal allografts, which you'll see, which you all probably utilize. We can talk about allograft strips as a reinforcement. And now there's something on the market called a composite biointegrative, and this is combining the in-growth with strength at time zero. There are two companies out there now. I have no business with either one. One is called Embody, and it's called the Tapestry, and the other is called the BioBrace. And these are actually grafts that have strength at time zero, and they're in-growth grafts. The bioinductive scaffold is in-growth only, has its tissue paper, has zero strength. So be aware of what's out there. I don't have any examples. BioBrace just got approved by the FDA six weeks ago. But these are out there. You've got to go to the booth and look and kind of get familiar. And then we'll talk about the bridging and interposition, understand it's an off-label usage of allograft. And we'll talk about SCR and dermal versus autograft, and J.T.'s going to help us a lot on that. We're going to talk about the spacer. And then J.T.'s going to talk about amniotic tissue and whether or not it's something we should be thinking about in our practices. So this is a case-based presentation topics. You'll see here we're going to go through these, and Mark's going to lead us through that. Let's talk about augmentation. So in augmentation, really, here's a polo player, history of shoulder pain, falls, has a significant dysfunction, has a pacemaker, so we do CT arthro. And you can see that he's got a mid-substance tear with a lot of tissue left on the tuberosity. Here we are. And so this is a tendon-to-tendon repair. We're always worried about white tissue, the white tissue in the cuff. We put ripstop stitches above and below the tear, medial and lateral. And then we put some sutures behind both of these for ripstop technique. Still a little bit worried about whether it's going to get it to heal because it's so avascular appearing. So we go ahead and drop an allograft in. And so this is a dermal allograft. This is a true augmentation. It spans the tear repair site and is anchored on either side. So that's a true augmentation. Ferguson, probably the best study, systematic review. In these tough cases, this is where the augmentation has been really shown its strength. And you can see here, 85% intact versus 40% in these tougher cases. What about graft reinforcement? This is a newer concept. This is not augmentation because these little strips are not anchored on either side. They're simply extra tissue. And we have a case of that. But this is a reinforcement. What about interposition and bridging? This is an off-label usage because it covers more than a one-centimeter gap. And this is a gentleman who had two failed cuff repairs when he came to see me. He's an oil field worker, massive tear, pain, weakness, pseudo-paralysis. We come in and what you'll see here is a lot of avascular sort of scar tissue. So we clean it up. He's got kind of a stiff cuff. We go ahead and measure. We go ahead and pass our sutures around the periphery. There are many ways to do this. And here's our graft here on the outside. We'll go ahead and drop the graft through, tie it around. It's just suture management. And because we're not using anchors, you don't have to worry about tangling. You can take care of it very easily. And then we'll fix the lateral side like we would a cuff. And this is what it looks like when we're done. You can see tissue sitting between the acromion and humeral head, both on the chronosagittal views. And you'll see here, I didn't have a prefilm, but he was a pseudoparetic and now he's gotten his motion back. Not a lot of strength, but we reverse his pseudo-paralysis. It's important to know why this works. Mahada study, we all know about this. If you go from the glenoid to the tuberosity, we know it can hold the head down. But remember, going from the cuff to the tuberosity can also hold the head down. Not as much, but it can. And here we're going to talk about this. I hope we'll have this discussion, SCR versus interposition. I'm moving more towards interposition versus SCR. And then what about SCR? And this is, JT will again enlighten us, this is a 57-year-old fellow. He'd had a prior acromioplasty, still pseudoparetic, and he's got a big cuff tear. And you'll see here on the left, he's got humeral head migration. He's probably Mahada II. And on the left, you can see he's got the pseudoparetic pattern. He's a young guy, he's only 57. And he's wearing sunglasses for the HIPAA stuff. They typically don't wear them in my office. And then here we are. And this is actually an SCR with an augmentation. So we're going to go ahead and do a biceps, a superpectral biceps tendesis. And then we'll go ahead and cut the biceps and save the tail. We'll go under it. We'll go ahead and prepare the glenoid. We pass our graft. We do a typical SCR. And then we're going to go and anchor this biceps on top. So this is kind of like the space shuttle. You kind of see the biceps sitting on top of our graft. And this hopefully will give us extra collagen between the acromion and humeral head, because I think that becomes an issue. This is what it looks like post-op imaging. On the left, you see the humeral head riding high. And on the right, you'll see evidence of pretty good-looking collagen, at least we hope, sitting between the humeral head and the acromion. And here he is five months out. Still wearing sunglasses. And you can see he's happy. Well, you can't tell he's happy. His arm moves better. Let's put it that way. And so the histology is kind of interesting, because I want to have this conversation with the fellows as well. This is Hartler's explant seven months out. And you can see on the periphery, you get some cellular ingrowth, vascularization. But in the center, it's about 5%. So these allografts do incorporate, but we're talking about a little bit less than maybe we had hoped for. And the controversies here, and JT will handle these in terms of graft size, what's the position of the arm, do you close the front and the back, you know, anyway. I want to have the conversation about simple interposition for long-term concerns. And merzyme, this is a very interesting study. And we've seen this actually in some of the other recent studies showing that in the failures, if it stayed on the tuberosity, people did pretty well. But if it came off on the glenoid, it didn't. So JT's going to raise the issue of spacer versus enhancing the forced couples. And we're going to talk about that. And so, you know, quibono, is it worth it? And I'm beginning to wonder about that myself. And the subclinical spacer, and Dr. Gettleman will talk about this. This video is courtesy of Mark, because they were a beta site. And Darren Low's study, the MOON study, and there's a big European study now showing the results aren't bad. And they're pretty durable. And this is a five-minute operation. It's now been described percutaneously under CRM control with the patient awake. Drop it in, blow it up, and go home. And then the bioinductive scaffold, this is a little different. This is basically the patch. It's a bone vine, Achilles tendon. It's like tissue paper. So it's zero strength, time zero. But it's an ingrowth. It's like a true biologic, in my opinion. This is my very first case. It's a 49-year-old fellow. I fixed his right shoulder with a complete and repair. And now he has a tear on the left side. And he does not want to go through what he had, what he had to go through on the right. And so we do some pre-op imaging. He's got a high-grade intra-substance that actually breaks through the articular side. Here we are asking, what if you can add additional tissue? And that's what this scaffold might do. And you just thicken the cuff. Can you essentially unload the tissue surrounding the tear and start a healing response? And it's felt that this is how it might work, because this is disruptive technology. It's placing something away from the actual pathology, yet you get the pathology to heal. So it's felt maybe on a biomechanical basis. I'm not sure myself. We're looking. Here's the fellows. We don't touch the rotator cuff. We just look. I don't want to have any confounding factors. We're just looking at it. We don't debride it. We don't do anything. We simply place a patch on this, or the implant, I should say. And everyone's just sort of seeing this and done this. And here's what it looks like here. So this is the imaging, our first one. Pre-op in 2015, and you'll see six weeks, four months, two and a half years out. It's a pretty normal-looking rotator cuff, and all we did was place the scaffold. So again, something to consider. And so what about the fact that we have these big tears, massive revision cuff tears? These are really tough to get a good result in. Can we utilize this for that situation? This is a woman with two previous cuff repairs. These are tough. These revision cuff cases that come back, and you've got to hang the crepe because it's not easy. You'll see on the top, original tear. After two failed cuffs, she's got two slides, two images on the bottom. She's got some scarring of her cuff, and it looks like she's going to have a type two cho failure, because the last one was a double row. And this is what it looks like here. Right shoulder, looking from the lateral portal, you see she still has some cuff. It's a type two cho failure, so it's a more medial failure. So it's a short cuff. So we medialize the footprint. We do a single row, modified Mason-Allen suture configuration. We go ahead and we'll microfracture the footprint, the marrow vents per Mark Edelman and Steve Snyder. We drop our graft on top. And this is what the gal looks like pre-op. You can see the head's sitting a little high, pretty ugly looking. Here we're six months out. It's a pretty good looking cuff for the circumstances third time around. There are some, there's some material out there. This is Buddy Savoie, so it's a little unfair because, you know, in his hands things are always a little bit different than the rest of us. But these are some really tough cases here, and you'll see utilizing a maximum repair plus the scaffold that he got 22 or 23 of these very, very difficult tears to heal. So this scaffold may very well be something to be considering. And again, some of these scaffolds that have strength at time zero might be even more suitable. So we'll talk about that. I think that evidence will be coming later, but again, it's early for us to have any clinical data on that. So here's what I would tell you. You know, this is 2021, and everyone in this room here has probably done a lot of rotator cuff surgery or interested in it. And I just have to tell you that all the things I just mentioned, you have to be comfortable with. You have to get good at an SCR, augmentation, even placing the scaffold. And I think that our results will be better if we do that. It's not necessary in every case, but I think it can be an important part of a procedure. Remember that the scaffold is a true effect of biologics. So when you talk about orthobiologics, I think it falls in that category. And certainly these tougher cases where the collagen and the tissue is atrophic and avascular, it may be very helpful. And I would just say that if you're a well-informed shoulder surgeon, you need to be very facile with information, what's out there, what can you use, and then ultimately how to do it technically in a correct way. Thank you very much. Thank you.

massive cuff tears

bioinductive scaffolds

dermal allografts

surgical approaches

rotator cuff surgery