issues that we talk about in this regard, and I do have disclosures that are relevant on this one, so you should take what I say here with a grain of salt, maybe an entire lick of salt. We always do, J.T. Yeah, okay. A 51-year-old carpenter, when we get, a lot of us see these kinds of cuff cases, right, with interlaminations, and we have options here, but they're pretty tough. We know that debridement doesn't work. Steve Weber showed us this many years ago, and it's been reproduced in study after study. So when we take a look at regeneration, we're really talking about biologic growth factors when we get there, and where does this biology come from, and we spent a whole day at the beginning of this meeting on the Biologics Association about what we're looking for. We now know that the, quote-unquote, stem cells probably doesn't react that way in vivo, and so really what we're talking about is growth factors. So what can we do to get growth factors, and maybe you put collagen in there, maybe you put some of those things. From my standpoint, we got very interested in placental tissues, and the reason is is that they are probably the single largest source of growth factors that, for pro-regenerative kinds of processes in the body, that there are. And so, to make a long story short, this is out of my lab. We took these placental streamers, and we analyzed them independently, blinded with our histologists and our immunohistochemists, and what they found was is that the growth factor profile is incredibly angiogenic. So that was promising, right? So we think maybe this is something to do with things that you're trying to treat, watershed tendinopathy. So where does that happen? Well, cuffs, and lateral epicondylitis, and Achilles, and et cetera. So if you go back to our case, this is, can you run that video, please? This is an amnion delivery system, and again, I'm conflicted here, so please understand that. But this has been my approach over the last year or so. This is an allograft umbilical streamer. There's no problem with the FDA. You've heard a lot of stuff about umbilical cord stuff, but that's ground up or liquefied. This one's an allograft transplant. It works just fine. We've developed this inserter here, so you can see this nitinol fork-tipped inserter. This is how it's going to be put in, and it's inserted inside this suture lasso. So for any surgeons that are out there that are used to shoulder surgery, it's incredibly simple. You can see I've already placed two streamers here, but I wanted to demonstrate the technique. Now I've loaded the placental delivery system. Remember the growth factor concentration in the billions in this small little streamer, and you can see that we can insert it right in that delaminated cup. So just in the interest of time, we're going to move along. This was my index case. We had a radiologist. We didn't even ask him to read it, and he came back and he said, what'd you do? It healed, and so it's an N of 1, so don't take too much out of this. We're still early in this process, but relatively pleased with the pre- and post-ops if you take a look at what the tendon regeneration, or at least healing, may be in this regard. What about full thickness tears? Well, you can put the streamers inside tissues. So for those of you that use internal braces, we now have a bio-internal brace, if you will, and so we feel like we want something that has mechanical strength as well as biologic growth factors, and for us, we think this is a promising way to deliver both, if you will. So for now, for me, for example, we've started doing SCRs, now bio-SCRs, right? So these have the potential to add these growth factors to these areas. What about other applications in this regard? This is interesting for us. This is in office, if you just run this real quick. So this is a patient of mine who's a retired football coach. Now he plays golf, did pretty well in his career, and so he's struggled with Achilles tendinopathy for a long time, and so this is using the inserter with a little amnion and a chronic Achilles tendon. You can do this right in the office, and you can do this under ultrasound guidance, if you will, and just in the interest of time, I'll show you this. This is his pre-op, or his pre-procedure one, and then this is three months later in his post-op, so we look at that and go, gee, something's going on here. It's way too early for me to declare victory on this stuff, but in terms of options when we talk about the potential for augmenting tendinopathies, watershed issues, this is fairly promising and something you might want to consider, but we certainly got a long way to go before we're ready to declare that we've got a scientific proof to this. So we're at the beginning of the next revolution. Biologics will move from snake oil to science, and amnion, I think, shows promise in degenerative tissues, especially watershed tendinopathy, so thanks very much. So we covered a ton of material, and I hope you guys have found this entertaining and useful, and I hope we've given you more things to think about as you move forward. Are there any questions from the audience as we start to finish up here? Can I ask, does anyone else use amnion? Question? Mark Wickman. Love it. Do you have a choice to put your regentin on the articular side or the articular side? No, it is an articular defect and an intertendinous defect, so the intertendinous issue. Of course they would. Of course they would, but you can't put it there. I would have to use a suture material. I don't think I would use a stiff implant over the humeral head. I would be a little bit nervous of the friction between the articular surface and any of the staples, for instance. So if you said, could I pass some sutures and perhaps, like a mattress suture? What if you could just sew it in? I think that's reasonable, but that really is not going to help me with the footprint. That's only going to help me with the intertendinous portion of it. So I think the intertendinous portion or the high-grade partial thickness tear, it will help me. But if I'm trying to get the footprint to heal, I need something to go further. So I think I might be a little bit better, and I'm not sure that synovial fluid is a helper in this or an enemy in this. You could also just microfracture your tuberosity too and get your footprint. Yes. Dr. Tovarich, I think I heard you correctly. You said you won't do an SCR if the supraspinous muscle looks bad. I'm curious, if you're not repairing the supraspinous, what does it matter? So first... Oh, subscapularis. With reverse, you mean? You said you wouldn't do an SCR if the supraspinous muscle was gone or dead. So I guess I would say if it's supra and infra. So the supra, I don't think, has all that much to do with function of lifting the head, right? So if the supra's gone, that's no problem for me. But if I have supra and infra where the muscle is dead, I don't think you'll get muscle back. It's just, I mean, I don't understand why that would ever happen. So for me, that patient, if you've got dead muscle in that posterior superior cuff, that's the patient that gets a tendon transfer. But if it's fat, it's fat, right? So I would not do it. But I think the exam would, because if your teres minor is functioning and your infra's out, that doesn't disqualify from an SCR. So if they have a lag and they have a hornblower, you've got to worry that putting an SCR is a fool's errand. But if they have external rotation positive and their teres minor is hypertrophied, that should not disqualify from an SCR. Yeah. So a functional patient's a functional patient. We're treating pain. So an SCR's still on the table for that patient. And I promised you I wasn't going to be done with acromioumoral distancing. If you can, there is sometimes like a boutonniere deformity where there's muscle that's intact, but it's no longer in a functional position. And if the head could be improved in its position relative to the glenoid, relative to the acromioum, all of a sudden the external rotation effect, you're not going to take a complete lag sign. But weakness in external rotation can sometimes be improved just by having partial reduction of the humoral head. But now if it's pain only in that case and you've got no muscle, what about just releasing the suprascapular nerve at that point? Yeah. So that's been bantered around a bit. Just not to go into any detail, there's a recent study out there that took a look at it with no advantage in that situation. So I think that's a little bit of an operation that's waiting for an indication. Although I love doing it. But there have been a number of patients who get a release of the biceps. The original Walsh study of 209 biceps tenotomies, and we're not necessarily promoting it, but there are a number of patients who have done fairly well. Also to address you, you know, what's making a comeback are partial repairs. I'm going to tell you, well, do SCRs. And I think there are reasons to do it, but I think we're a little overly zealous using the SCR. And I think partial repairs are making a comeback. So, partner, so you're willing to do a partial repair, but you're upset about throwing the biceps and trying to make it a complete repair using your biceps and your partial repair concept combined? Well, you know, my concern is does that biceps incorporate into your repair? And so I've done a few of those, and I like to get scans. As much as it's stupid to get scans, I just want to see, hey, am I really doing anything here? And I've got to tell you, it doesn't look very good. So I've been turned off by my post-op scans. And the patients do okay, but, you know, I guess the lousy looking scans are a lousy looking scan. Yeah, you've got to lower your patient's expectations. Any other questions? Well, we're like a group at Starbucks. We could go on for days just sitting around talking about this, but we have to let you go. We're going to get yelled at. I want to thank you all for your attendance and your paying attention to us here. Please be sure to fill out your evaluations.

placental tissues

growth factors

regenerative processes

biologics

scientific evidence