I will say that when we thought of the, you know, when the balloon came out, all of us, right, I'm sure all of you too, said, man, that would be awesome if it was permanent. And so we ran and checked the IP on it because I thought, man, if we can get the IP on this, this is awesome. So we went to a breast implant company and then a testicle implant company. So just to keep it gender neutral, the testicles were too small, sorry, fellas. And we thought, man, this would be awesome. But in fact, the company did a beautiful job of locking up that IP, so more power. Was that an allograft testicle or an autograft testicle? Bovine. I want to know what I'm signing up for when I come to Arizona. So this is my disclosure. And again, this is a 61-year-old retired right-hand dominant firefighter. He had an initial cuff repair in 2009. And actually, he did pretty well post-op by his history. I didn't do the surgery, so I'm just taking the history from him. He had a revision in 2014, said it was better after the surgery, but still had some pain and weakness. You wonder, did it heal or fail fairly soon? Then he had another revision in 2019. His motion, he thinks, improved, but his pain did not. And now he's presenting to me with three previous rotator cuff repairs. And he's coming to me six months after the most recent surgery. And so now he's failed three cuff repairs, and he's active, and he's just got really a lot of pain, especially night pain is his big thing. He just can't sleep. So interestingly, as JT was showing, his muscles are actually pretty good for a guy that's been through three cuff repairs, which just shocked me. And he has good motion. He's not pseudopoietic. His subscap is intact. And you see the imaging. He's got a CHO type 2. So this is a tough one. It's musculotendinous. He's got a lot of tissue left on the tuberosity. This is now the fourth time around when we go in. And so the question is, what do we do? And so Mark, this is kind of probably just easy for you, but how would you handle this? Yeah. When somebody's failed three times with what looks like good surgery, these are the ones that worry me, that they could have a P acne or C acne, whatever you want to call it today, infection. So these are the ones that make me a little bit nervous because, like you said, he's got good muscle. And I don't think you're in a world where really I want to start thinking about reverse when they still have muscle. But when I'm now talking about putting in a hunk of dead tissue and I'm worried that they may have some low-grade infection, they make me nervous. So these are the ones that I'll try to aspirate if you can. I usually don't get anything, but I would be concerned then. So he went through the whole panel. We didn't aspirate him, but basically every test we see, everything was normal. And our cultures at the time of surgery were normal as well. And I'm just telling you, but we were worried about it as well, but we just did not have any indication this was infection related. So that was, I would also do that. But there's two different types of failure. There's an individual who never gets better from their operation, and whether it's stiffness and issues of inflammation, that's more of the P acnes type patient, or just failed collagen restoration. There's another individual who actually gets better after each operation and then has either some unknown, whether it's a firefighter, unknown traumatic event, and it's basically a tear of a weakened structure. This is one of the explanations why the muscle may look so well, that he actually did heal each of those previous operations as opposed to failed three surgeries. I would say that he had three rotator cuff tears in this particular case because of the quality of the tendon and the muscle you have there. So I would look at it as you're going into a fairly, you know, it's in a location where clearly you're putting a weakened structure back together. It's a piece of aluminum you bent 10 times, and you're trying to see if it could hold up the body weight. You're going to have to do something to it. But I would not, after I ruled out infection, I would be pretty encouraged about what you're going to do. JT? And he said, you know, he goes, it's pain. Yeah. You know, it's not that he can't throw a fastball. He goes, I can't sleep at night. It just always hurts. Yeah. So I think that's exactly right. It's just a question about what is his complaint. You showed it. He's got great strength. He's got great motion. And he's failed twice already with two six-month rehabs. So now we're going to... He's failed three times. Three times. So three six-month rehabs, and I'm going to offer him a fourth. I look at this and I say, well, I'm thinking about other things. And so obviously you've ruled out the infection, blah, blah, blah. Does he still got a biceps? I can't imagine he still does. No. So no biceps left. So then you're looking at it. So then we have a discussion about how, what's your appetite for, we can go two ways here. I can do a quick one and get you back pretty fast, but I'm not going to fix that cuff. Or I can do a long one and we're going to buy in for everything, which would for me be sort of an augment with whatever your augment is, yours is. All right. All right. Anyone, audience, what would you do? Anyone with experience something like this, your fourth time in, we're hanging crepe, we're all saying, hey, listen, this is kind of black box, don't know what's going to happen. Anyone have experience with this sort of setting? Nobody wants to touch that one. Yeah. All right. All right. So I'm going to jump in here and, and you'll see here, he's got the, you know, the cuff tear, stiff tissue, remaining suture. This is a Cho, this is a type, actually his biceps is there, isn't it? Do they put stitches in the biceps? Is that? Yeah. No, no, no. His biceps, I thought his biceps, but it's not. This is an instant. This is a quick cooperation for me then. All right. So here it looks like, you know, it's stiff and, you know, not too bad for three times around, but this is, you can see here, actually, you know, when I bring the arm down, this is going to be in a lot of tension if I try to bring to the medial edge, if I medialize. And I tend to medialize now quite a bit, probably four or five millimeters on most of my repairs because I do a single row, much like Mark and Steve described. And so here we are. Does it change what you would do at this point, Jeff? Yeah. I don't think he could just keep going back and doing the same thing over again. So I definitely, I didn't want to allude to that with my other comment, but I would be fixing this with an augmentation of some kind. When you say fixing with an augmentation, you mean repair it, then put a patch on top? Yeah, I think that would probably be if I thought the muscle and tendon looked like it was in a pretty good place, I would try to do a low-tension repair and then extend the lateral margin with the graft. So you see it's under tension now, so as I bring the arm down to the side, clearly it's under tension. Now, do we decide we have a biceps or we don't? Yeah, yeah, Jeff. Biceps is there. Jeff, you taught me that. So no, I would, excuse me, thanks for kicking me under the table. So I would probably use my biceps and save my $3,000. So I would actually repair the tendon, put the biceps over the top, and use that as my hair extender and use the long head of the biceps to attach. That's your second hair extension reference today, Jeff. Aren't you concerned about the amount of tension on this? I mean, I could do the max repair, release in the front, release in the back, split it, bring it over, bring the biceps on top of it. Why do you bring it on top? So no, so let me just show, the reason why we would avoid the over-tensioning is we'd have the cable in front restored with an anterior anchor or posterior anchor. I wouldn't try to do like four anchors across the tuberosity and try to get it all down. I think if I got the anterior cuff down, the posterior cuff down, and use the biceps to incorporate the middle part to the tuberosity, I'm good. So you would not bring the edge of the cuff back to bone. You would basically interpose the biceps between the tuberosity there. That's correct. Do you use the same thing? Yeah. I must say that Jeff taught me about this. He said you should consider trying to use it, and I've gone to that a lot, originally because of the cost. And I must say he was, as usual, right on. And I've done probably, I don't know, 20 of these now, and the results have been shockingly good. So what they're describing is you do a suprapectral biceps tenodesis, then you do a tenotomy off the glenoid, then you flip that tail, the proximal tail, into the repair site. I've done that a few times. Distal tail. I personally don't like it, but these gentlemen are saying that it's something you should consider in these situations. The other point here is, you know, people in the past have talked about, you know, Burkhardt particularly doing slides. And I think once you start doing slides, you've got two little cruddy pieces of tissue that you can't do a whole lot with. So my experience, certainly with a posterior interval slide, is it's not very good. And now you've compromised your ability to have functional tissue, because this still has good muscle. So in my mind, the question is, do you try to do a release and see if you can get it over, or do you just add some extra tissue? And you don't have to hit a home run. Your infraspinatus is almost always repairable, and usually not with a lot of tension, despite the nature of the anatomy of the infraspinatus. So you're really talking about a residuals-isolated supraspinatus defect, and the question is, how do you handle that defect without over-tensioning it? Well, what's interesting, a double interval slide is different than an anterior interval slide. And I do an anterior interval release, I should say, commonly, and you should all be very comfortable because it gives you one or two centimeters of excursion. Just take the rotating interval out, look at the CA ligament, follow it to the base of the coracoid, and just take everything in your path, and that cuff moves forward amazingly. So you should really consider these stiffer cuff tears. But a double slide's a little different. I agree with Mark. Sometimes you can do a double slide and have a little postage stamp, and you're saying, all of that for this is probably not worth it. That said, let's just show you what we did here. So decision making, here we go. So we basically decide here, I think the tissue's stiff, I don't like trying to bring it back down to bone. However, the muscle's pretty good. So again, from my professor, Gettleman, I said, you know what, I want to preserve this, so we're going to do an interposition graft here. And I think that we can preserve the muscle, I think we put some tissue in here, and I think we can help him with his pain, because function's really not the big issue here. So we microfracture the typical stuff, and we're going to go ahead and just do a single row, and we'll place our anchors, we place our sutures around the periphery. Remember since these are not going through anchors, I don't worry about tangling. I can untangle everything because I'm not going through an anchor. So we do this, we whip through these pretty fast, and just one by one, find our sutures and tie, and then we're ready to go. So this is actually a fairly quick operation. We're just measuring here with a chia. And we drop our graft in here in just a second, and here's our graft in place, medial, and then lateral, we use a single row lateral side. And this is what it looks like post-op. Oops, let me come back one. Can you go back one, please? Everybody wants a movie star in Santa Barbara. Can you go back one, please, on the slide? There. So we are three months post-op, and you see that we've incorporated this out graft very nicely into this repair. And I have to tell you, amazingly, really within two weeks, he said his night pain was so much better. I mean, it was impressive. I was shocked. And here he is, this is four months post-op, and he's got, you know, all his motion back. He wasn't pseudopredic, but he's just happy as a clam. So I think this is a reasonable alternative in this case, and I felt better in my chances of healing than trying to do a maximal repair in a guy that already failed three times. And then there's some stuff out there. If you look at interposition graft, we talked about that, why it may work by, again, helping hold the head down. Plus, you're preserving that cuff and that muscle, which is now working. And then you look at this, this is a low study here, SCR versus interposition, no difference. This has just been accepted for publication. And the only thing to show is that if the grafts fail, they aren't as good, if they came off one side, they're not as good as if they were intact. But SCR versus interposition, very similar. This is a Wong study here. It's actually being presented here at this meeting. Same thing, maximum repair versus interposition. The results are phenomenal. Look at max repair, 87% recurrent tearing, and in the bridging group, 21%. So again, something for you to think about when you have these big tears, you're going, I'm going to be heroic here and do all these things. You may turn up, you have good muscle, decent tendon edge, then an interposition may very well be a very good alternative, and it's not an SCR. So again, I'm leaning more and more towards this. Great job. So we have 15 minutes left. We're going to just run through three quick cases, not going to have a lot of time.

discussion

medical professionals

rotator cuff repairs

infection

surgical options