So, to that point, this is a quick one we'll run through, the young patient with the high Hamada. So, this one, you know, this should be a short discussion. Well, let's just do a reverse for this guy. This is a Hamada 3, easy, right? So, anybody else recommend something different, Jeff? Would you do anything different than a reverse recommendation on this guy? Failed surgery up against the now starting to get acetabulization, I think you've got a problem. Yeah, that's a real problem. 58, though, I've got to tell you. Yeah. Worries me big time. So, he brings up a great point, right? So, the literature in patients who get reverses under the age of 60, and that's why this is a pretty interesting case. Under the age of 60, the biggest study in the literature so far has been Romeo's group. And what they found is that three years, they already had a 25% failure rate in that group. And that's Romeo's hands. That's a pretty good surgeon, right? So, 25% failure in three years with an under 60 person. Even Romeo called it a limited goals procedure, which is a little bit like salvage, which I say is a little bit like shitty. Okay? So, when you think about what we're going to do with this patient, and this guy helped me because I would love to do a reverse in this guy. Again, I told you, I don't repair the subscap on purpose. And so, he says, what are my restrictions afterwards? And I say, you don't have any. You can come out of the sling. You can do whatever you want. And we've been doing that for seven years now and data coming out on it. And so, that's my fastest recovery. I can't talk people into rotator cuff repairs anymore. What fails? What fails? What? What fails in three years? It's pain. It's a little bit of loosening. It's all the usual things that you get, hematoma, dislocation, et cetera, but it's mostly pain that they get. They don't get a ton of loosening in that group. These are 58 years old and they have higher expectations than, I think, some others. And the poly wear and the notching underneath the clenoid, some of the mechanical issues are more pronounced in these. Because they have bigger ranges of motion and they have bigger activity levels. So, I think their poly doesn't do as well as it would be in an elderly person. Okay. So, I did talk to this guy. He's had two previous cuff attempts, but here's his thing. He's got great muscle. So, this is, for me, the only slide that matters in this particular case is that I look and I say, gosh, he's got really, I mean, great muscle. So, like I say, where there's muscle, there's hope. And then I said, look, how about a reverse shoulder arthroplasty? And he wasn't having it either, which was nice because it made my decision easier in the sense that, you know, that was off the table from the beginning. So, those are our possibilities. We talked about this. So, this is my current algorithm of this. Okay. So, if you have somebody who is age greater than 65, let's call it physiologic age with DJD, that's an easy answer for me. If you're less than 65 with no DJD, then my question for you is, do you have good motion and strength? Getting back to your point, is this just pain? Okay. If you've got good motion and strength, then, like I say, do whatever you want. Cut the biceps, do a spacer, do rehab, anything you wish. It's all going to work. It's been shown in the literature to do that. That's when the patient who has a functional shoulder with a massive cuff, we've all seen that a lot. Now, here's where it gets tough. If you've got poor motion or pseudoparalysis, now the question becomes, do you have good muscle or bad muscle? If you've got good muscle, well, then it's worth it. And we do SCR or we do interposition or one of those techniques. But if you've got bad muscle, well, then this is the one indication for me for a lower trap transfer, which is an incredibly good procedure for restoring these kinds of things and getting good pain relief. Do you have any comments, just like an acute-on-chronic, so what happens to a person who has now a traumatic event that they change their functional activity level? Jeff always asks the fricking hardest questions when you're up here. There's always one guy, right? That's a hard one. And you've taught me a lot about that, but I think if you've got an acute-on-chronic, if their chronic state was reasonable, then I think you can do an acute operation to restore them back, rub the tummy of the dog, and get it to quit barking. Is that fair? Would you do something different? No, I think that's right. That's one of the things that you get more aggressive with some type of repair work and doing something. Yeah, you're good. I'm feeling an urge in my bladder when you ask the question, so thank God I got it right, Jeff. J.K., you're assuming the subscap is functional in all these, certainly on the right-hand side. You're talking about a lower trap with the subscap has to be intact. Subscap needs to be intact. It has to be. If the subscap is out, however, then, I mean, you've got, you can either do an anterior capsule reconstruction or some sort of transfer, but you have to get that subscap. Right. You have to get it out to a lower trap if the subscap's not repairable or somehow can be addressed. Yeah, sorry. I should have specified this as posterior superior cuff insufficiency. But how do you get proximal migration like you're showing with normal muscle? Well, I think it can be dysfunctional if you have bad tendon. But when you show that MRI, his muscle is normal. I mean, it looked like an intact normal 50-year-old with normal functioning rotator cuff. I just don't understand how you can get that level of dysfunction with acetabularization with normal muscle. Yeah, good point. So I will tell you, this is his MRI. But you're right. That's probably a rarity to see that kind of muscle in that shape. And of course, if he's got poor muscle, then I think this is a much easier discussion as we go forward. So what do we do with this guy? Well, you know, this is one of the lessons that we've learned. When you compare Mahada's data, right, which is there's two problems with comparing the American experience, if you will, and the so-called Japanese experience, which mostly comes out of Mahada, is that we do two different things. One is his patch is way thicker, okay? And what he's shown over and over again is thickness matters in this regard with these papers, 8 millimeter better than 4 millimeter, and then TFL was better than human dermal allograft. I actually believe that, that human dermal allograft is probably inferior, but not because of the thickness issues, because of the stiffness issues, right? We pull on these things and they'll stretch. You pull on an allograft tissue or TFL autograft and it doesn't stretch. So about a third of my grafts now are autograft. And I will tell you that I like doing the autograft, especially in someone who I've got to restore function in. In somebody who's painful, the allograft is great. But in somebody who's functionally deficient, that's a little bit tougher. But the thickness also matters, right? So how can we make the graft thicker? And so when we take a look at this, single versus double dermis was also taken a look and they say, if you double dermis it, you can get a thicker patch. The problem with that is that there's no way to really do the double dermis, either you're putting the outside to the outside or the inside to the inside. Do you want it to heal or do you want it to glide? And you're in this catch-22, right? So now maybe that doesn't matter or maybe it does, but this is our approach. Can you run that video, please? Hey, Jay, before I... Yeah. So on the panel, I want to ask, does it matter? Does dermal side down versus the epidermal side in the long run make a difference? I watched a very famous surgeon perform one of these live over in Germany and we were laughing about it because he put it in upside down. Nobody in the crowd noticed except me because the furry part was showing upside down. I was like, how'd that go? He's like, I had to turn it over in there. I go, does it matter? He goes, it doesn't matter. I wonder if I'd have put it in. He probably said, that matters. I think it matters a lot, but there are some who are saying it doesn't, but I would tell you, you have to know the dermal shiny side goes down and all the grafts are different so you can't just use one graft and apply it to another vendor. But I think dermal side down is very important and I think the healing potential is much less if you put the epidermal side down. So I think orientation is big. I mean, basement membranes, you know, histologically for sure it matters when you talk about what we're doing here, skin, et cetera as well. So you know, so here's the thing when you, how many of you do SCRs? Can I just see? Yeah. So all of you, right? So what do you do? You measure the patch, you cut it. What do you do with the other half? We throw it away. So we all do. So I got thinking, well, why don't we just use it? So just run that video if you would. And this is, this is this guy. So he's, this is his pre-op and his post-op. Let's go back a slide if you would. And if you go into the video itself right on there, yeah, and just hit the play button if you would. So this is actually a little bit of an older technique. I now use three anchors across the top. I use all suture suture anchors and they're all knotless now. But you know, for those of you that have slid this in, I saw Mark's video earlier and how beautiful that parachute went in. That doesn't always look so beautiful when it goes in, right? And you all know this. If you get this in upside down or you twist a thing or you get something stuck, it's a crappy day. I mean, these are, these are hard cases, but anyway. So this is the SCR that's, that's going in over the top and I always repair my graft beyond that level. So and then I always repair posterior and anterior. Why not? People say, well, you're going to make them too tight, but you can cut the patch as big as you want. So there you're done with that. But then this is the key to this. This guy's got Hamada three type changes. I need to increase that space as Jeff mentioned. So this is the technique we described. We measure this on the other side and we simply just use the other patch. Originally, I was taking these through like an old ACL guide and putting it right through bone to fix it right down to bone. I don't think that's so critical anymore. I actually just go through the AC joint. It's actually quite a simple procedure. So this is the other half of the patch and we're just placing a mattress sutures through each of the corners of the other end of the patch. This is the, as I said, that sort of description of that, use just a little nitinol wire. That'll give you your passing sutures. This is through the acromion and now we just take it like you would anything else with suture management. We're managing the anterior part. This is a spinal needle that's coming on the anterolateral border and then old school, those of you that are old school, remember the PDS passing stitch to where you just grab it and then you can tie the half hitch and pass your stitch back. So now we've got the two anterior medial with the white suture and lateral as it's coming through here. Once that's done, I can simply just put the patch in. It's a hell of a lot easier than the big SCR patches that sometimes are really hard to put in here. So that one's real simple. Now you can slide this guy in over top. You don't pull them as much as you push them sometimes and then you reduce that guy down. You've pre-passed your sutures on the other side. Remember watching Jeff do rotator cuff repair and I always thought he was putting it on 4X speed. He was so fast. Still feel that way about him. So there you go. So now I've got my two back sutures in. We pull that down. There's your SCR on the bottom and now we've taken advantage of the top and we call this the SCR plus procedure. So a couple of interesting ideas about this and then I showed you. These are his post-op pictures that we brought his head down. I'll tell you we're about, I don't know, two years, three years out from this guy now and he's maintained an increase, although not quite as good as he was post-op as we go forward. So same result. You can see Shenton's line pretty poor and we were able to restore that in that regard. So in conclusion with this particular technique, I'd say that SCR is viable if you have good muscle. For patients with high riding heads, I think a thicker graft does improve the biomechanics. The SCR plus effectively doubles this graft thickness and resurfaces the acromion and then provides the potential cuff reconstruction and a permanent, and that's the key here, permanent biologic spacer. So my question for you is of course, do I need to do the SCR? And that's my question. So if I have a patient now and they can come in and they can do this with pain, but it's a Hamada 3 or Hamada 2 where you're high riding, sometimes I'll say, look, I can do, here's the problem with the SCR, it's a long rehab, seven, eight month rehab. So a lot of times I was doing this and I'll do an SCR minus, that means I'll just resurface your acromion, but that's hard. So that was a mistake on my part, I think. Now we've switched now where I'm just doing the SCR minus, but I'm doing it on the humeral side and just put down a big thick human dermal allograft right across that humeral side. And for those patients who aren't pseudo-paralytic, it's an excellent pain relieving operation at least early, but more to follow. Thanks very much for your attention. Yeah. Great. You know, what's interesting, Gene, there's a very good paper out and it's by Lanchetta and Pete Millett, and Pete Millett from Vail, and they report on 22 SCRs, very honest reporting, nine of the 20, no, the 25, they had 22 with imaging post-SCR, nine of the 22 failed, nearly a close, almost a 40-some percent failure rate in very, very, very, very good hands. So that I don't know about you, but all my SCRs don't heal. But everyone's saying if it heals on the tuberosity and comes off the glenoid side, you still might do okay, as JT's mentioning. I have not had that, so I've had failures on the glenoid side, healed on the tuberosity side, and they still remain symptomatic. So this is much more than I think just, I think, a sort of buffer there. I think there's something more to that. So I think it gets complex, but I do think holding the head down is a big part of this. You want to do your next case?

Hamada classification

reverse shoulder arthroplasty

failure rate

treatment options

SCR plus