Welcome to the Multi-Institutional Sports Medicine Fellows Conference. Please keep your computer muted during this talk out of courtesy to Dr. Ma. This is being recorded and will be transferred to the AOSSM playbook on their website and will be available on the Learning Management System starting next week. If you have any questions, please submit on the chat function and Dr. Cohen and myself will ask at the end. If there's any faculty that would like to comment, please let us know and we'll unmute you for this as well so that we can have some good interaction. And I again encourage the fellows on the call to ask questions. Dr. Ma likes the harder and more obscure questions the better. So without further ado, it is definitely my pleasure to introduce Ben Ma. He's Professor in Residence and Vice Chair of Adult Clinical Operations at UCSF. I've known Ben for quite a long time, hired him to UCSF and he's taken over and taken it much further than I ever could take it. So congratulations to Ben and Ben's going to talk about advances in management of rotator cuff diseases. I don't like to talk about fashion when I'm talking about Ben because if you've ever seen him dress day in, day out, that's, you know, there may be some question there. So without further ado, Ben, thank you very much for doing this. Appreciate it. Well, thank you, Mark. You know, thank you, everybody. And, you know, I think that everybody's going through a slightly uncertain time right now. So, you know, hopefully we'll stay connected. And thanks again, Mark, for putting this together as a great group of talks and glad to be a big part of it. So I'm going to share with you guys a little bit about advances of fashion in management of rotator cuff disease and over the next 45 minutes or so, hopefully we'll have some time to kind of discuss, you know, some fashion trends going on. These are some of the disclosures, doesn't have any pertain to my talk today. So what is the current concept? What's fashion over there is like a trend. I think, you know, for us in sports medicine, we do a lot of trendy things or cutting edge things over there. And a trend is a general direction in which something is developing or changing. So it's fashion. So, you know, it depends on the day of the week, you know, or the month of the year over there. There may be different things you're doing, different fashion you have. So this is the fashion kind of a layout for the day today. So we'll talk about, you know, how the fashion of rotator cuff diseases. So these are things we're going to touch on. So single, double or triple trans-osseous repairs. Should you really operate? What flavor can you add to your repair today or is it fat, fat or more fat and balloons over there? Okay. So there are five topics we're going to focus on over here. First one, you know, talk about this single, double or trans-osseous over there. So you guys could put on the chat in terms of what you guys do, you know, in terms of your fellowship and also in practice right now in terms of single role versus double role versus trans-osseous repair. So you know, we were kind of part of the movement early on. So I think that a few of you guys, you know, in the, in the call today was part of this movement. I think that in the early 2000s over there, we were so excited about how good we are in terms of doing rotator cuff repairs. We kind of, you know, thump our chest, you know, we stand up on the podium, we say, oh, yeah, I never open anymore. And we actually do single role repair at that time. And then they're very sobering, you know, result that came out from the Washington University group as well. We could do these repairs, but they don't do very well. A lot of them actually re-test. So there's a big movement in the mid 2000s and say, well, you know, is it the way we fix it? Should we fix it stronger? Because we're used to do such simple sutures. So we were kind of, you know, I have a lot of, you know, biomechanics study done at that time to show that, well, if you do a double role fixation, that's stronger in terms of the repair. There's more, you know, coverage in terms of the, you know, tendency to bone. So which it kind of gave birth to double role fixation, which actually put two rows of anchors. Then it become trans-osseous repair, which makes it a lot easier in terms of, you know, passing suture and tying knots over there to like ultimate, you know, some of the, you know, more faster devices that can be done, you know, at this point. So there's a lot of excitement on that over there. And I think that, you know, for the past 10 years, there have been, you know, good data right now to show that, well, you know, even though that biomechanically is strong, there's no great clinical data to show that there's such a difference in terms of outcome. So patients do well, either doing single row or double row. If you re-image these people, I think for the, you know, for the double row, there may be a slightly lower re-tearing for some of the bigger tears. We talk about medium, large, or massive rotator cuff tendon tear. For small tendon tear, don't make yourself strapped heavy that day by putting, you know, another, you know, anchor in. I think the results are not different at all. So it's pretty clear cut, you know, what the outcomes are, I think, you know, for some of the trainees, you know, in terms of, well, once you do double row, you know, think about it over there. Most of the time they can do a simple repair, may be adequate. For a bigger cuff tear, I think, you know, maybe added fixation may be needed over there. So now the challenge we actually face with, you know, double row fixation is that we created something a bit different. So we used to kind of, you know, fix these tendon, and if they fail, they fail the suture tendon junction. If you're lateral over there, when they tear, you still have quite a bit of tendon left. The problem when you do a double row fixation, if they fail, they fail the medial cuff, which is close to the muscular tendons junction. It adds another layer of complexity where you need to revise these. These are the type 2 tears over there, which we don't see a lot, you know, in the past, and now it's certainly become the issue. So when you actually have a very, very strong repair, pull the tendon down really well, you may actually put too much tension, and you fail more medially, and it's going to be an issue. The bigger issue, instead of focusing on fixation, which is kind of what we did in the 2000s, I think that, you know, the last 10 years, you know, I think, you know, I really kind of advocate also talking to my fellows and residents, I really recognize the tear pattern. A lot of these tears may not be able to couple straight down to the bone. You may have to do some side-to-side repair first, take the tension off, and then do the tendon to the bone. So recognizing tear pattern is good. Less is more. I think that's the plea for the group over there. Now the law talks about when to operate, or should we really operate. Obviously, most of us have not operated over the past five to six, you know, weeks over this, and most of the rotator cuff tendon can be managed non-operatively right now. So what is, you know, what is the data out there? So Jed, which is the leader of the MOON group, which, you know, a few of us are in that group, was involved in this study, and she looked at about 450 patients with chemo with asymptomatic, you know, I mean symptomatic, atraumatic, full thickness rotator cuff tendon tear. We actually, you know, prescribed them with the evidence-based rehab program, and we actually tracked them to see how they're doing at 6, 12, you know, one or two years after surgery. We asked them the question, do you feel you're cured? Are you better? Do you want to continue physical therapy? Or if you know better, we're actually going to go do surgery and want to see what the outcomes are. And it's actually pretty surprising when the results came out, you know, 10 years ago. We found out that a lot of patients do well, you know, less than, you know, 20% of people actually end up having surgery. If people do choose to have surgery, they choose surgery within the first, you know, three to four months. So if physical therapy is going to work, it works pretty early on. If it doesn't work over there, you know, actually, if it's going to work, you know, I think it's going to last, you know, a while. If it doesn't work over there, they find out pretty early it doesn't work over there. So you know, what are things actually not predictors of having surgery from that study? Surprisingly, you know, we as surgeons always focus on the size of the tear, how big the tear is, you know. Turns out that, you know, the number of tendons are torn, the amount of retraction, the amount of, you know, forward flexion of the, you know, a patient at the, you know, index appointment, the duration of symptoms, the pain level, were not predictors of whether the patient needs to have surgery, which is surprising when we actually first, you know, think about the study. The anatomy itself, no association, you know, symptom, no association. There is some association when you actually have, you know, higher baseline activity prior to injuries or like an active person do a lot of overhead sports, are less likely to do well with non-operative treatment. Non-smokers, surprisingly, you know, have, you know, failures of, you know, a non-operative treatment. So maybe they are, you know, more aware of their bodies and more concerned about, you know, what is going on younger age. We kind of expected that over there. The biggest, strongest association, which is kind of, you know, interesting, which we kind of find out to learn more about this is, you know, part true for most musculoskeletal diseases is that the low patient expectation. So the patient comes in and say that, hey, I don't think physical therapy is going to work, dog, you should opt in on me. Well, those people are the ones that probably won't do well with physical therapy alone. So I think that's something, you know, that I use it in my practice to guide patient in terms of, you know, informed decision. We'll ask them, hey, you know, you could do physical therapy, you could do surgery, but, you know, a surgery that could lead to this outcome, non-op treatment that a lot of people do well. They actually don't really have faith or think that physical therapy is going to work. Those are the ones that may actually, you know, turn over to surgical treatment, I think would be better for them. Now the question that, you know, you probably ask if you do, you know, a physical therapy is, well, you know, could the tear get bigger? When it gets bigger, is it becoming irreparable over there? Patients do need to understand that tears do not really heal. There's a, you know, risk that the tear may get bigger over time. And there's also this muscle degeneration we're going to talk a little bit about later on. And also age affects it. So somebody comes in and when they're in the 65s, well, if I don't fix it now, when I get into 68 years or, you know, over there, would it be worse over there? I think those are the data we don't have, you know, a few years ago, but we have more and more recently. So we're talking about not acute injuries. These are all chronic injuries. These are, you know, symptomatic, atraumatic injuries over there. So these are degenerative tears. When you look at the rotator cuff tendon, this is actually a slide that Jay Keener shared with me over there. The, you know, arrow is actually where the anterior band is, you know, over there where the bicep tendon is. So anterior is on the left-hand side of the screen, the right, posterior is actually on the right-hand side. Where the tear usually start about, you know, middle part of the tendon, where the, you know, the supraspinous tendon midpoint is. So as you start, you know, the tear starts about 50 millimeter from the anterior edge of the rotator cuff tendon cable and actually extends anterior and also posterior. That's where most of the degenerative tear starts over there. This is actually a nice study done by Mike Kim that look at, you know, where the tear, you know, propagates or where the, you know, incidences actually show that it's actually not tearing from the anterior part of the posterior, it's actually tearing the middle part of the tendon and extends anterior and posterior over there. The degenerative tear usually start about 13 to 17 millimeter posterior to the bicep tendon. Most of the tear don't involve the anterior supraspinous tendon and one of the things we do find out that if it does involve the cable, it's much worse. So you know, the patient may ask you, so I'm going to get better after physical therapy, right? Is the tendon going to heal? Is that true? You know, is that right over there? You know, the tear won't get worse, you know, won't it? That's a question you get all the time over there. So this is actually also a nice study by, you know, Jay Scribner from Wash U to look at, you know, progression in terms of, you know, when the tear gets bigger. So you know, the y-axis is the survival, you know, curve and x-axis is actually time. You found that when people have baseline full thickness tear, they do tend to progress with time. How much over there, you know, 22% of them will progress, you know, in two years, 50%, you know, at five years. Partial rotator cuff tendon also progress, which is the brown line over there, which is a little bit lower. And obviously, you know, the black line is actually, you know, no tear is actually what, you know, what they tend to, you know, develop with time over there, okay? So you know, who are the people that actually have a higher risk of progression in terms of the tear? So the larger tear tend to, you know, have, you know, a higher risk of progression. If we actually have a recent like tear enlargement, means if you had MRI done a year prior and another, you know, MRI done right now to show that the tear is, you know, getting bigger, the most likely to continue to enlarge. If you enlarge more than a centimeter, they actually make it more, you know, at risk also. You know, when I look at the MRI also, you know, focus a lot more on the anterior edge of the supraspinous tendon near the rotator anterior cable where it is. If there's a structure in the anterior cable, they're actually more likely to expand also. So those are the things we're concerned about. And also the muscle changes, if you see like, you know, a year of enlargement, actually muscle do actually have more degeneration over there. So this is actually an interesting study done by Moosmeier. I think this is kind of much needed. It was done in Europe in terms of a randomized study looking at surgery versus, you know, non-operative treatment for rotator cuff disease. This is a five-year study at that time, found that surgery does, you know, have, you know, better outcomes in the constant score and ASES score. But at that time, you know, we didn't really, that study did not, you know, achieve what we call MCID, which is minimal clinical differences over there. But you know, there are about 24% of people in the physical therapy group that crossed over to the surgical group. And for the non-operative treatment, you know, about 37% of, you know, these people have, you know, anterior enlargement. They do seem to be a bit worse with time. But at five years at a time, there was this difference significantly, statistical difference, but not clinically significant at that time. Now, that was 2015 that Moosmeier reported, you know, those data. You can see some of the difference in the constant score and ASES score. Constant score for most of, you know, you're actually familiar with is actually focused a little bit more on range of motion. ASES score is a little bit more on strength also. So I think you see a little bit difference in terms of ASES score because we do have strength, you know, loss, you know, with rotator cuff injury, whereas early on, you may not have as much range of motion loss. So the constant score may not pick up the difference early on. So that's important, too, when you actually interpret data, is that when there's actually a different tool to look at outcomes, it may not show what you're looking for. So when you look at range of motion, constant score is a better score, you know, to use. When you really want to look at symptoms, maybe an ASES score is going to allow you to kind of look at something different over there for you. Now, you know, same group, Moosmeier with the same group of patients. Now they're the 10-year data they published, you know, last year. So it's a 10-year study, fairly good follow-up, 91 out of 103 patients able to kind of come back for follow-up. Now they actually found that the primary tendon repair is better in physical therapy, almost a 9-point, you know, improvement in constant score and a 15-point improvement in ASES score. So these are both have reached MCID right now and also 1.8 centimeter on the VAS score. So clearly now that we have good data is that when you follow these patients 10 years out over there, there, you know, is a difference with primary repair versus, you know, physical therapy. OCK trial is actually a trial done by the MOON group. We're actually actively, you know, seeking patients to do a multi-center study. Moosmeier study is a, you know, is a, you know, is a center study about 100 patients. So the OCK trial is a U.S. trial that a few of you guys, you know, part of it that we want to enroll about, you know, 300 patients across the country to look at randomized, rotator cuff repair primarily versus supervised physical therapy. So the same study that was done by Moosmeier, but bigger scale. So hopefully with this study, we'll actually be able to kind of look into the more variables and who are the people that do well with physical therapy, who are not. Overall, I think that surgical group do better, but obviously physical therapy, there's still a lot of people do great. So who are those people? So without the numbers in terms of a larger trial, you won't be able to answer those questions. So the question sometimes people say, well, the study is done already. Why do you need to do it again? Well, the idea is actually now actually change the scope of the study to try to look at, you know, different variables in there also, which is exciting with that. Okay. So what flavor can you add to the repair? I think, you know, you know, we're going to talk about what I mean by that over there. So, you know, sometimes people will say, you know, what kind of flavor do you have for boba tea in the San Francisco area? That's what we ask for. So what could you add to a repair? Can you add PRP to the repair? People ask about, you know, I have a patient coming also right now, doc, are you going to put something good in there to make it heal better? Is the stem cells over there? I heard about this great, you know, treatment called crimson duvet. What is that over there? So we have a lot of Cal Bears, you know, over here. So they hate red over there. I know that, you know, there are a lot of Stanford people over there. But so a crimson duvet is, you know, what is it? And what is it good or bad over there? So I think that those are questions you may have. So what is the data out there? So PRP has been used for a while right now, as you know, some of you guys would know, there are some, you know, randomized control trial on PRP used for rotator cuff, you know, tendon tear. This is actually one of them done by Joe in 2015. A randomized control trial, 74 patients over there. No real difference for clinical score or patient reported outcome. But when you do an MRI on them, there seem to be lower retairs on the PRP versus the control group. So this is actually one of the early randomized study. This is actually a double blind study on 82 patients over there. Have a little bit shorter follow-up, you know, in terms of this group. Again, PRP versus control. The PRP seem to have a little bit more pain early on, you know, but then there's also no difference in terms of some of the patient reported outcomes over there. But it seems to be some improved structural integrity at six months over there. Wang et al over there is actually, you know, published, you know, using not a single dose PRP, which is, you know, have the, you know, rotator cuff surgery done and do a PRP at seven and 14 days afterwards over there to try to kind of get a different phase of the, you know, recovery. And get an MRI in 16 weeks over there. This study did not show any significant differences. They are studies not just doing a time zero, you know, administration of the PRP. I'll do it later on to see what the differences are. So this is something I did, you know, last year on this, on terms of PRP, using, you know, it for rotator cuff repairs. Most of them were found that for the PRP, they have, you know, a slightly improved retail rate. But, you know, for clinically in terms of measurements, there's no difference in terms of rotator cuff scores that we have. So ASES score, UCLA score, clinically, there's not a lot of, you know, demonstrable differences. But for the imaging part, they seem to be better, you know, healing over there. So this is actually a meta-analysis, you know, done, published in the CCOG. I'm sure that there seems to be some inconsistent, maybe a smaller benefit of PRP use. There may be some benefit on other conditions other than, you know, rotator cuff like EOA or lateral epicondylitis. This just came out, you know, recently this month. Dave Flanagan from Ohio State did a meta-analysis that looked at 16 randomized control or prospective cohort style, cohort studies. Majority of time, the PROs are very similar. So again, no clear clinical differences when you ask for the patient, you know, how they feel with, you know, imaging to look at structural integrity, PRP seems to have a lower failure rate, which is good. However, there are a lot of different preparation of PRP, so sometimes difficult to interpret these results. I think most of you guys have heard multiple talks about that right now. Not all PRP is the same, not just between difference in terms of, you know, the company or different, you know, set, but also the patient, you know, lots of variability even among patient or within patient. Means in my PRP today, giving a talk, you know, when I, you know, put my PRP out, it may be very different this morning after I finish a big breakfast over there. So my PRP probably is better after my big breakfast over here. So those are the difference. Now, how about, you know, bone marrow stimulation or crimson duvet or putting like an anchor that's vented with blood that comes out over there? What does it do? So they have, you know, some studies done, you know, two level one study and two level three studies. essentially there's no difference, again, in clinical and functional scores. For the pooled retail rates are 18 with the bone marrow stimulation, about 32 without it. So, you know, if you really wanna, you know, look at odds ratio, there's a 0.42 difference, but, you know, the data is very limited right now. I think it's not so clear about, you know, the benefit in terms of, you know, this particular technology. Now, how about stem cells? You know, I think that most of, you know, you guys practice may have heard, you know, patients saying that over there. I'm kind of fortunate, you know, I'm working right next to the Gladstone Institute, which is Dr. Yamanaka, works, you know, literally about 300 feet away from us. He's pretty well known. We just walked by his institute. We never really see him in person, but he's a Nobel Laureate. The one, you know, the award that he's able to turn any pluripotent stem cells into any cell types over there. And he's gonna laugh about what we do in orthopedics right now. So, you know, we have all these stem cell treatment over there. We take cells from your fat, we take stem cells from your skin, take stem cells from whatever place you get your hands onto over there, spin it down and we, you know, so you put it in the, you know, you know, the joint and put it in repair and magically the stem cells is gonna figure out what it's gonna do. And he's just gonna laugh about it. You know, in his lab over there, he has to have a particular, you know, environment, put a growth factor, whatever, you know, things that kind of get the cells to differentiate, delineate. We don't do that, but we think that we're orthopedic surgeon that the stem cells know exactly what they want to do because I told them to do so. But for whatever reason over there, we, this is kind of taking off in some parts of the world. I think that, you know, it remains to be seen that when this technology is gonna go away. But I think the most important thing is that there is potential for stem cell treatment. It just that, you know, it may not be, you know, that, you know, efficacious with the way we're doing right now. There has to be some type of engineered approach to tell the stems of what to do. If not, it's very easy for them to go the easiest path, which is like, you know, fibroblasts over there for them. So how about fat, you know, a fat and more fat over there. So, you know, these are some of the, you know, things we talk about, you know, a lot in rotator cuff, you know, surgery. So, you know, we do understand, you can almost see a little bit how the field has evolved over the past 15, 20 years. So we start out a little bit talking about, you know, arthroscopic surgery. We're very good about able to do arthroscopic surgery in the late nineties, early 2000. And we found that, oh my God, we didn't do such a good job. It's open, let's fix it as strong as it can. Two layers of anchors, you know, three, you know, double loaded anchors, triple loaded anchors over there. Then as well, it's not so, you know, important. Let me try to get some healing to the, you know, the tendon right now to kind of put, you know, blood in there, put, you know, pocos in the bone over there. And then for the past few years, we've focused on, well, you know, how about the quality of the tissue? We focus so much about improving the environment, but what about the tissue itself? So we found that, you know, obviously for rotator cuff muscle, if there's a lot of fat infiltration, atrophy, they have a high rate of, you know, retains. And I think that multiple studies have actually been shown before, but we didn't really pay attention to it until probably the past eight to 10 years ago then. So, you know, Fox and Coutelier came out with a, you know, Coutelier classification in terms of looking at the amount of fat within the muscle. So you look at, you know, grade one down here, the one, two, and three, and four, in terms of how much fat there is. And it turns out, you know, when you actually have, you know, Coutelier classification grade two and above over there, the results of, you know, the tendon healing is much lower. So, you know, I kind of always have this little, you know, game with my fellows and, you know, and trainees in clinic is that it's kind of, you know, funny when everybody look at the same MRI and when we come out the different, you know, different amount of fat that's in there. Almost the same thing as when I look at the mirror and say how fat am I myself over there, my wife would say that I'm really, really fat, overweight. And I said, I'm like, you know, I'm like Brad Pitt over there. So it depends on who's looking at the film and how busy you are that week, how many cases you want to do. I think the fat content changes sometimes. So it's kind of a very objective way, and not a very objective, it's a very subjective way of evaluating it. So are there ways that we can measure fat a bit better? And how much fat is really too much fat? We know the grade two and above, but what does grade two really means over there? So it may be great that we have a scale or something we can measure and say, oh my God, you know, that you have like 15% of fat, out of the question over here, this is too far gone. Or, hey, this is actually not too bad, this is actually a fixable tail within. So this is something that, you know, our group has spent a lot of work on over there, and this is something pretty exciting. I'm going to share with you all. This is actually being rolled out to possible as a clinical, you know, scan sequence that we're actually able to do in the future. So this is called ideal imaging, which is actually some modification of sequences on the most of the MRIs. It could actually look at fat content. So we actually did a study that my partner Drew Lansdowne did over there to look at, you know, the amount of fat measured by, you know, ideal sequence versus the, you know, classical tally and classification. We found that the lower ideal, you know, fat measurements, the, you know, the lower the good tallies classification, and then you can see that almost, you know, beyond grade two, like a level of maybe like, you know, 10 or 11 above, then they actually go to the threes and fours. So you do have a big difference in terms of fat, you know, measurements with these ideal measurements. Now you have to have an objective way to measure it and see how much fat there is. We also look at, you know, who are these people that have higher fat content over there? We found that, you know, for people that actually have three centimeter bigger test, they tend to have higher fat content. Same thing with the amount of traction. The older you are, you also have more fat that's in there. Same thing with, you know, BMI. And, you know, in a female, you know, for whatever reason, the high fat content compared with male and longer duration of, you know, symptoms seem to have, you know, more. So these are something we found that actually related to high fat content seen on the MRI over there. So this is actually, you know, a study look at, you know, small, medium, large, and massive rotator cuff dendritic to see how that, you know, ideal fat content goes up. So now you can almost like, you know, do an MRI scan instead of just looking at how big or small your test, you know, maybe we could give you some new information in the future to say, hey, that fat is whatever amount over there. And you could actually, you know, put that in your decision in terms of what needs to be done over there. So I do actually take this a little bit further to actually look at a group of patients who actually did surgery on, with the scan done ahead of time, also a scan done afterwards to look at, you know, whether the muscle changes in terms of the fat content, and also, you know, related to, you know, their rotator cuff repair integrity. So these are patients that I should look at over there. So this is actually the fat fraction after rotator cuff repair. We look at, you know, overall, if the fat does, you know, continue to go up after, you know, a repair, mostly actually it is on the supraspinous tendon muscle that seem to have some progression, even though you fixed the tendon. So the process doesn't stop after you repair it. Everybody's always, my fat's gonna be normal after a while. Number one, they don't reverse, and they actually get worse with time. So it depends on, you know, where the condition is. He also found that if you actually have an intact repair, that, you know, the increase is fast, it's much lower versus your failed repair, that, you know, the fat content goes up, which is kind of what we expected, you know, to see. And this is now something we actually can measure, I can tell people also right now. So we look at like a revision rotator cuff repair, what is the value over there? I think it's important to kind of, you know, see these numbers over there. So I think ideal image is pretty exciting for us, you know, over there. Hopefully this is something we could, you know, again, more clinical experience and share with everybody in the future. So high baseline fat fraction observed in larger, you know, tear sizes. They're small, but be a consistent increase in fat fraction of supraspinous muscle following repair. Well, I say that super tendon, you know, it says even when you repair it, it can get worse. Preoperative fat fraction is significantly higher in people with failed repair. And this is maybe a great way to monitor effectiveness of your treatment and also look at muscle deterioration, because this is just a study up to a year right now. You can imagine if you have a repair that done, when could a patient go back to sports? And if that sports is harmful or helpful for them, we can monitor outcomes right now. So instead of just looking at, is it torn or not torn, you can measure quality. So when you talk about, you know, the repair, the injury over there, you know, when something's torn, you obviously want to fix it. Is it fixable? And now we could, you know, tell, you know, with these images. When you fix it, what's the likelihood it's going to tear? Again, you can see the quality of the tissue. Hopefully that will allow us to kind of monitor tissue even a bit better with time. So this is not just done by our group. You know, there's a group, you know, from Japan that use a similar imaging sequence. It's called two point Dixon scale. It's a little bit, you know, maybe a little bit less iteration than the one we use, but it's very similar in terms of what they found. They also found that, you know, the fat generation in supraspinous tendons is actually much higher when you have bigger tears. They do actually tend to deteriorate, you know, with time and also the female patient do have, you know, some higher fat content, which is what we found early also. They also have a similar study looking, you know, repairs afterwards also. They found that, you know, the fat content does go up if you have failed repair versus an intact repair over there. So fat quantification, you know, I think is a negative prognostic factor. So hopefully in the future with enough studies, we have been established almost like a cutoff, you know, for people in terms of what is a cutoff that, you know, is good, because I think most of us, you know, would know that, okay, smaller tears heal better, massive tear, you know, heal worse, but we actually still fix a lot of massive tear if they are acute injuries. So when you have an acute cup avulsion, these are big, big tears, but when we fix them, the results are very different than a chronic, degenerative, medium-sized tear. So the acute cup tear, they may be big, but if the quality of muscle is good, the results are okay. So another thing to think about, not just size, not just retraction, now we look at quality, which we don't have great data before in terms of able to measure. So now I think this would be helpful. So now hopefully, you know, we actually have a scale to measure people instead of just, oh my God, is that okay? Well, you're too high or too low. They may not be able to fix it. So last but not least, we talked about is patches and balloons over there. And I think that hopefully, most of the fellows this year, but I guess the experience of trying some of the newer techniques is available out there. I'm not saying that one is better than the other, but I think it's kind of good to see a little bit about what has been done before, what may be coming in the future. This may be something we can use it more in our practice or may not be. So this is one of the early experience of using patches. So Lenard actually reported their data in 2015, 16 patients using like a synthetic augmentation patch for open rotator cuff repair. Found that, you know, people have, you know, in reasonable improvement ASCS score, but, you know, they do have some retails in a particular group. This at that time was used as a augmentation. This is a Ferguson review, look at 10 studies looking at allograft augmentation, you know, versus xenograft. They do have more inflammatory reaction with the xenograft and found that, you know, people could actually have some improvement with this. Most of these studies are using these grafts as a augmentation, not a bridge. I think most of us would agree now that when you have a tendon that you cannot fix, there's a gap in between, these patches doesn't work as well. So most of them actually use an augmentation that when you fix a tendon, well, not as good tissue can actually put something to augment it. These are some of the data that's out there. There's also some new, you know, product available. This is one of them, you know, called Regentin. It's a highly post-coated xenograft that have been, you know, advocated. Initially, it came out, was to kind of advocate a useful partial tear cut repair. So when you have a partial bursal side of tear or even a partial articular side of tear, the idea that if you put this patch on the bursal surface, you could kind of share the load between the, you know, muscle to the, you know, the bone and take the tendon off that allows the tendon to heal better. So this is one of the initial experience over there that patient actually, you know, do have improvement and also some, you know, increase in thickness of Regentin in the tendon itself. And the more impressive is that actually this data actually been published, you know, last year by Buddy's group in Tulane. Buddy's a very well-respected, you know, rotator cuff surgeon, rotator shoulder surgeon over there. He has great technical skill, awesome surgeon over there. But if a massive rotator cuff tendon, tendon tear, even for the best of hands, we're looking at about 40, 50% of healing rate, you know, these are chronic, you know, non-acute injuries over there. When you have a chronic massive rotator cuff tendon tear, I tell people, I fix you. And the image is down the road, 40, 50% of the time, you know, you have a tendon that's actually healed down the bone. Majority of the time, it's actually still torn. So he actually, you know, in this, you know, study, 23 of his patients with massive or, you know, a large rotator cuff tendon tear, when he repaired them, he augmented with this bio-inductive collagen patch. He did an ultrasound on them at three months and also MRI, you know, on average a year out from surgery. And found a 96% healing in two years. So this is actually significantly better than what we had before. So when you actually look at 96% healing, you know, in two years, we're talking about our simple, small rotator cuff tendon tear. Those are like about 90, 95% healing. These are massive rotator cuff tendon tear. So these are very, very good results over there. Obviously, this is a single center, you know, report. This hasn't been really duplicated yet, but this may be something that's, you know, that's here to stay in terms of helping us to augment the repair. The difference between this product compared with the previous product is that they do kind of process this, you know, this tissue to allow a little bit more pores in growth. So hopefully that may actually lead to more tenor site going on to it. That's the idea, whether that should transform to the clinical, you know, significance. I think more studies we're able to kind of, you know, show that. So, so far, I think, you know, for patches of 2020, these are small cohort, you know, series, you know, they're not good for bridging. They may have some effect for augmentation, but clearly we actually need, you know, larger cohorts and more randomized studies out there. Now, SCRs is something interesting. SCRs are not really, you know, a patch. It has actually completely changed the way we do, you know, a surgery for people with rotator cuff deficiencies. So instead of attaching the patch, one end to the muscle or the edge of the tendon, the other side to the bone, SCRs, as most of you guys know, is attaching, you know, one side of the patch to the glenoid and the other side to the greater tuberosity. Basically, it's almost like a barrier. So you basically put it to kind of avoid superior migration of the shoulder. So how many SCRs are being done per year? You know, I think the numbers float around. We talk about thousands, thousands over there. Up to 10,000 over there in the US. So I think the numbers are going up. And I think it'll be interesting to see what's the data out there so far. Okay. So this started with, you know, Dr. Mihata. He's actually working down at UC Irvine with a Thai Lee. He actually did some study in terms of, well, you know, when we actually have a massive rotator cuff tear and tear, when you actually activate delta, the human head will rise up. Why can't you just put something there to block it, right? This is such a very biomechanical, you know, thinking about, let me block that, you know, ball, the ball will not rise up. Obviously that's what they show, right? They put a patch on top of the shoulder, sew it to the neighboring tendon so it's still intact over there. You keep the ball, you know, below the axis of the rotation and the ball will not rise. I think it definitely normalizes superior, you know, migration. He used that same, you know, a study extended, you know, and actually used it clinically. Now you talk about translation, he did a study in the U.S., went back to Japan and did some of these studies over there and found that when he used a tensor fascia latograph, which is not what we're doing in the U.S. right now, you harvest a tendon, fold it up, usually about eight millimeters thick, it was sewed into the glenoid and do these, you know, patients over there found that the patient do have much improvement. These are, you know, significant improvement in terms of active range of motion. And also, you know, the acromion humor distance is also, you know, bigger. That's actually how much, you know, the patient can actually do with the glenoid. That's actually how much distance between acromion on top of the humor head. Also patient has significant improvement over there. So when this study came out, everybody was like, wow, you know, what is this over here? It's pretty exciting in terms of technique. So he also, you know, looked at what it does, you know, in terms of using a thinner graft. So when you do say four millimeter graft versus eight millimeter graft over there, the eight millimeter graft does have better result. That's what he has been using in the past. So, you know, it's very different from how it's being commercialized in the U.S. The U.S. actually, when you have a patch, you can actually open a kid to take it out. They're usually a few millimeter thicks only. They're also not your own tissue. So the results may be a little bit different, but in Japan, the results from Dr. Mihara group, but he also did a multi-center group, also showed, you know, fairly enviable results, I would say. And this actually, you know, his results, you know, more recent, look at, you know, 100 patients over there in terms of, you know, what they do in terms of going back to sports or actually go back to work because they're concerned with these patches, well, it's not very durable. They may not be able to kind of withstand when you do more heavy, you know, work, or also maybe do sports. And it's found out that patients actually do quite well in the hands of, you know, the Japanese surgeons over there. Well, how about the U.S.? We've been using that for at least, you know, I think five years right now, I think, you know, when it first commercialized. This is actually one of the early reports of a hyperpenitent in arthroscopy. He has 88 patients, minimum one-year follow-up. He had, you know, great results. Only four out of 88 patients have failed, but it's a one-year follow-up, and it does have increased, you know, acromion distance. There's a little bit more sobbing results came out, you know, from Danone. Danone actually had 59 patients over there. They do have improvement in terms of ASES score, but it's about, you know, 20% of these people undergo revision surgery. About seven patients, you know, go to reverse. This minimal one-year follow-up, you know, I think it's one to four, you know, one to three in this group over there. So not a long-term follow-up. So consider, like, revision surgery happened within first 24 or 36 months of the operation. 20% underwent revision, and seven, you know, patients underwent reverse replacement. That's actually not a small number considered this group over there. So I think something concerning about the U.S. experience, again, the experience in the U.S. may be different from Japan because the technique is different. So, you know, it may not be completely transferable, but also we need to kind of be careful about, you know, what we're doing. This is a tutorial, you know, in arthroscopy that talked about, you know, allograft, you know, and also dermal, you know, dermal allograft, or SCR. So he mentioned about the concern of the low rate of graft healing and the lack of improvement in the chromatin index. And he also considered about thousands of these procedures, I mentioned, have been performed in the United States right now. So I think that's something that be cautious about over there. And just kind of keep in mind, you know, what, you know, the indications are, and make sure that, you know, you as a surgeon would advocate with the patient. What is the long-term success rate? Now, I kind of lived through something years ago that has a lot of negative, you know, kind of a feedback early on was a reverse arthroplasty. So I do remember that, you know, when I was a, I'd call myself a junior surgeon. I'm a, maybe a little bit mid-level surgeon right now. When I was young over there, when reverse replacement was available, there was a lot of concern about reverse replacement. The first two years when reverse was done, so many dislocations, so many failures, so many problems over there. Then multiple studies have been published, and now reverse is probably the most, you know, commonly performed arthroplasty in the shoulder right now. So I think that obviously we need to learn from our techniques. We need to refine it. The most important is to track your outcomes over there. I think that, you know, for the SCRs being done right now, there may be a selective group that may be beneficial, but the most important thing, who are those people? I think we're very, very cautious about it, and learn from others. You know, why is it working in Japan? Maybe it's the technique is different. So instead of making a surgery easier, is that we need to make the surgery better. I think that's the most important thing, okay? So last but not least, I promised I'm gonna talk about balloons over there. So balloon for rotator cuff, you know, tears. I think, you know, some of you guys may have heard about this is coming. It's actually started in Israel as a company. There's a pivotal trial done in the U.S., so a few centers were involved in doing some safety trial here in the United States. It's a biodegradable of space. You literally kind of do an office, put the spacer into the cyber code space, fill it up, blow it up in the office. So the idea is to kind of keep the ball away from hitting the chromiums. Again, it's kind of like a barrier method to avoid superior migration. It does degrade with time, which to me is kind of not too sure why it would kind of be a long lasting outcome. So this is actually a data published recently in a journal that is not so easily accessible in the US. It's a minimum of five year follow-up in Europe, a 24 patient, 86% of people actually have clinical improvement, less than 10% of people actually have no improvement or worse in short scores. Obviously, it's exciting, but again, it's a small cohort of patient, no comparison trial. And also this is a new device and probably there's a little bit of a placebo effect for patients also when they're doing something new, they may actually have some excitement in relation to that. This is actually a follow-up study that was published this year. Look at 32 patients, 16 in each group, look at big rotator cuff tendon tears. If you do a partial rotator cuff repair in one group, which you can put it back down to the bone, versus you do a partial rotator cuff repair, put a balloon in there. Both groups seem to have improved clinical outcomes and no real difference between the two at this point. So people are doing more studies, right? If they find out what the outcomes are, so it remains to be seen. So in terms of current fashion in rotator cuff diseases, we talk a little bit about single, double, triple, and I think to me, less is more. Spend more time identifying the tear pattern. I think most of my resident fellows would agree that when I do the repair, it's not about fixing, it's about where it goes. Grab that tendon with your grasp and see where it goes. Most of the time, it's slightly like a reverse L shape, that needs to be slightly angled to bring it to where it's supposed to be. So I think identify where the tear pattern and where the tendon should go and fix it appropriately, I think it's good. Should you really operate over there? I think that you should. I think the data is pretty clear that operation can actually have good results, but if the patient have concern about, physical therapy is also helpful. There's some tears actually more likely to progress, but the surgery could certainly help these people with it, especially when you look at long-term outcomes. Which flavor do you want to add to your repair? For me, I'm a plain kind of guy right now. There's no chocolate syrups I put in there. There's no caramel over there. Plain is good. I don't see anything I add is gonna make my repair that much better at this point. Maybe at some point, the data's more clear, and we could use it, but I'm just not too sure that things available right now, as far as the preparation is very consistent. So the PRP data, it's very concerning, is that, well, we can't prepare these cocktails very, very consistently right now. So why am I using something that I'm not so concerned at this point? So fat, fat, and fat. So I think that hopefully in the future, we have a scale for it for us to measure. We can actually tell you what the numbers are and actually help with that. And for the balloons, it remains to be seen. It may pop in the future, but we have to kind of wait for more data on that. So I'm gonna stop here for a second over here. This is my experience I want to share with you guys regarding fashion. And I'm sure that if you're in the audience, we kind of share about the new fashion trends with everybody, it'd be great, yeah. We got what, we got what, we got. That was great, Ben. Appreciate everything that you just presented. You really hit all the highlights for sure. I would encourage all the attendees, if you have any questions for Dr. Ma, please feel free to put it in the chat. I'm unmuting some of the faculty as well to answer any questions. Thank you very much, Ben, or to ask questions. Thank you very much, Ben, for doing such a great thorough job there. We have, so Ben, what is your criteria for double row? Yeah, for me, it's really for the big attendees, if any. So I think that we talk about large and massive is when I use a double row. For small, medium-sized, I usually use single. I think, you know, I'm less and less common using the second row, because I don't think it's really that needed for the smaller tiers, yeah. But I think it really depends on what you want to achieve. I think it's not like, you know, for everybody, but for bigger tiers, it's more common to use it, yeah. When you do double row, are you tying the medial row or are you not tying the medial row? I tie the medial row. I do think that it's helpful to kind of protect the lateral, and I want to see what the faculty does also. I don't trust the bone laterally as much, especially with some of the fixation devices. You know, we usually use push-lock laterally. You know, if you don't tie medially, you do a push-lock laterally, it'll all pull out over there. If you actually have some of the devices, you can screw in maybe a bit better or actually lock in laterally. But if I do do a push-lock laterally, but if I do do a two-row fixation, I do tie medially first. What do you, Steve? Yeah. Yeah, Ben, I think really what you're describing, and I'd like Latul, and I saw Mike's also on, and Seth, you know, I think it's really important to individualize tiers and not necessarily say that you're going to have one thing or the other, that I always do double row or I always do single. I think that it really is a matter of evaluating each tier separately. Some are these high-grade partials that you end up completing or you do in situ, or ones that are more crescent tiers that have a little more retraction, and those need a little bit more to them. So I typically do tie a medial row and then do a knotless lateral, but I may use two anchors medial and one lateral or three medial and two lateral. So I, you know, it's not always a, you know, the trans-osseous equivalent. I don't think it's always necessary to do the same way every time. Yeah, Ben, yeah, that's a great talk, Ben. You know, I echo exactly what Steve said. For me, if I put more than, you know, two medial row anchors in, typically that means I'm going to do a lateral row. I tie medially, and I don't, I can't quote the article, but there was some benefit to tying a medial row and bringing it over lateral. I use knotless fixation, knotless for the screw-in device laterally. And that's kind of the way that I approach things. Yeah. Mike, you want to- Mike, anything different? Yeah. Great talk, Ben. It was awesome. We have actually a paper coming out, a biomechanical paper in OJSM here soon, and we wanted to look at exactly that. If you look at it, you know, because I think a lot of people would agree, if you don't tie the medial row, you're putting all your eggs in that lateral row basket. It always makes us a little bit tense. But I thought to myself a lot, when you have a double-loaded anchor and you pass those and tie those down, how unnatural it is on the tendon, because, you know, you're crimping all this tendon up. You're certainly not laying it down the way it wants to be. I've gone to a hybrid where I use a double-loaded medial row anchors, one suture, one tape, and I'll put the tapes out wider and the regular suture closer together. So I can tie down the suture and it doesn't cause this, you know, real high compression type, you know, forces that are abnormal, but then you still can lay it down. That's just what I've morphed to. So you're almost spot welding medially with a small suture and then you lay it down. That's a great concept, that's great. But I think part, you know, I would kind of make a plea to the fellows in the audience too, is that I think we spend so much time on, you know, structural fixation, mechanical strength, but the field has moved beyond that. It means that it's not how many anchors we put in, it's not how many sutures. You know, obviously we need to put enough so that it doesn't tear early on, but it's really about the healing potential. I think that the past 10 years that the field has really kind of changed. If we really focus on what are things we could focus at as a biologist and some things to do. I don't think the biologist available right now is really that great. It remains to be seen what could be better. We don't have anything better right now. And also, you know, how could we, you know, actually, you know, help the healing environment. So not just a biologist at time zero, is that what are things we could do afterwards? So I think that, you know, the PRP or whatever, you know, a cocktail put in may not be just at time zero, maybe like three months down the road or six months down the road. That's kind of part of what I think would be the future. And, but the fixation is not how strong it is because we have more type two failures right now that we don't see before because we're actually so strong and to put a tendon down, it just ripped me on the beginning of the tendon is just a bad tissue. So hopefully we'll get something good in the future. What do you guys think about biologics? What, you know, where do you guys think it's going? Is there anything that's in the horizon that you think would be exciting? Exciting in biologics, you know, nothing from my standpoint, as far as what I've seen from a delta rotator cuff feel faster, but obviously that's the, that's one of the holy grails in the shoulder, right? I know. Hey, Ben, I think what's good, I think the next horizon is going to be on the endesis, what's going on at the bone and, you know, are the healing capacity at the bone the problem and can we put down a new fresher endesis that allows a greater milieu or even more degenerative type of tendon a better chance at healing? Yeah, I agree. I think the data hasn't shown, you know, that PRP has been that effective and your comment of the reduction and the preparation are probably more important than what anchors, what sutures and what your format is and everything. So I would agree with that. Ben, there is a question from Michael Pullen that says, thanks for a great talk. Can you comment on your approach to partial or articulocyted tears, especially those in an intact cable, debridement with subacromial decompression or posture repair or takedown and repair versus bioinductive implant? So this is a partial articulocyted tear. Yeah, I think it depends on the tear width and also individualized also. If I see like a 40-year-old that comes symptomatic, failed non-operative treatment, if they have a tear that's 50%, you know, or higher, I would probably, you know, debride it and I would just fix it in situ like a posture repair. If it's someone a bit older, maybe like in their 60s, their tendon is not so good, they're kind of, you know, partially torn but not all the way through, but the tendon is more degenerated, I'll probably complete them and fix them on the subacromial side. I almost rarely ever do subacromial decompression anymore. I don't think it really helps so much. I think people talk about it. The interesting thing is whether some of these implants could, you know, help the healing. I think some of the data actually show earlier that have a small series that you put the, you know, the patch on top of the subacromial space and actually heal. It's interesting. You know, I know Rick Ryu quite well. You know, Rick, you know, and Jeff, you know, actually, you know, have been doing a lot of work on that. They're pretty excited about it. I haven't really done it for those patients. For me, I still mechanically try to fix them. What do you guys do? Yeah. Well, Mike, I think you could comment on this, but, you know, if you have a partial articular sided tear and a thrower, that's a totally different story than a partial articular sided tear, as Ben mentioned, you know, in a 60 year old. And so I think the treatments are different. Yeah, it's a tough, that's a tough problem in the thrower. You know, I'll be honest. I, you know, I was very bullish on the potential for Regenitin and the partial tears in the throwers that just weren't, they weren't able to get back to what, you know, to what they once were able to do. And as Ben showed with Buddy Sablaw's study, you know, Buddy has probably put more of those in than almost anybody. And he is hesitant to put them in the throwers compared to that other patient you're talking about, Steve. So, you know, I think Regenitin's great, but I think in the throwers, it's still up for debate. And I would caution trying to fix a pasta repair down in a thrower, because I think that the peel off is maybe an adaptive mechanism to get the rotation. And if you put, repair that partial thickness tear back down, you may limit their motion and you may end their career. Right. I think it was very clear, but I always agree. For overhead throwers over there, you know, in the twenties over there, partial cuff there, don't, you know, don't fix it. You debride it if you need to, get out of there. You know, 40 year old active person, partial cuff, you know, and 50% maybe pasta in my hands over the tissue is good. I still think there's some benefit from leaving the intact cuff in place, because whatever is healed and fixed is not as good as a native insertion over there. And older patient, I'm not shy about fixing it. And for those, I'm going to do single anchor, two simple sutures, nothing fancy, no double row for that one over there. Yeah. You know, the reps would not be happy, but you know, just single row is fine with those. Yeah. Hey Ben, it's two more questions actually, one from the audience and one from me. The first one from me is how are you changing the angle of your camera and how are you, have this multiple cameras going on you? So you must have a better setup, but the more important question is from Alexander Brown, who says, is there any data out there on fatty infiltration and that fatty infiltration happens for rotator cuff without tears as you age? Yeah, so maybe I'll ask the second question first over here. So there is, so there is data right now that our group and others have shown that as you age, there is actually a high fat content. So when you look at people 40 years old versus 60 versus 70 over there, there is a deterioration in terms of muscle quality, which put these people at risk, right? So older patient, their muscle quality is not as good and they also tear more often. So they're already torn, you know, if they're torn, their muscle quality is bad, their treatment's a little bit, you know, not as good. There's also a difference in terms of people with, you know, with hypercholesterolemia or diabetes. We don't have that, you know, data yet. We actually have a lot of scans we've done, but we're actually looking at some trends that, you know, some patients that medically, they actually make them more, you know, more high risk of the muscle quality, not as good. Female also actually have high fat content compared with male. So if you're a female with a rotator cuff tendon tear, the results of fixing it may not be as good. So something good to be, you know, male, you know, in some instance. So that's something we do find, but those are data we don't have before because we can't measure things objectively. So now we can measure objectively, hopefully it was going to change how we take care of these patients because the key is actually don't let the fat kick in. So are there ways that we could condition the muscle or exercise over there, or maybe injections or medication that can actually stop this situation? I think it may be helpful. So that's a, now, first question, Steve, you asked about camera, you know, can you clarify, you know, what do you mean by that? Yeah. Well, you, it seems like you have multiple screens that are showing your face during your presentation, so didn't know what you were- Oh, I don't know, Mark's kind of put my face plaster all over the place because of fashion over there. Maybe he does that like that. I just did it, you know, in the office over here. So I don't know how it projects over there. Hopefully it was okay. Ben has always been curious how he looks from all angles. So, you know, he's got multiple cameras on him at all times. I got one other question here from Gary Fan, but he had to get off, but about the fat as well, Ben. It says, does the fat index help determine your preoperative plan with patients with a massive tear? Does that help you determine whether or not it's gonna be, you're gonna be able to complete the repair? You're partial that, you know, that maybe go to SCR or reverse, or that surgery's not gonna help and they need therapy. So do you use the ideal sequences, the MR ideal sequences to help predict what you're gonna do in the OR, or do you just know what it's like, and then you just try to do a full repair every time and you get what you get? Yeah, I think it does. It may not be as, you know, as granular as you mentioned over there, but I think I use it as a way to kind of, you know, guide the patient in terms of whether surgery is gonna help or not. So for example, patient come in with a massive cup tear, if the ideal level is high over there, I say, well, this is probably not gonna heal very well. I know that the odds are 50%, you know, you're gonna, you heal 50% not, well, you know, with this number, you're probably even lower over there. So those are patients I may kind of lead them more towards non-operative treatment, maybe even doing replacement for some of the older patients, versus someone actually come in with acute or chronic tear, for the acutes over there, even as a massive rotator cuff tear, if the ideal looks great, I say, hey, this is not bad at all. This is a big, big tear, but your muscle quality is good, we should fix it. Or a lot of times we see is the acute and chronics. Well, you know, which part is really acute, which part is chronic. So I think having those numbers will allow us to kind of really guide them. Now, we're not so good about getting numbers for everybody, but that's the future. That's what we really wanna push this technology out there, and hopefully we'll get more data in terms of how it can help us over there, yeah. Cool. So Mark, I know you wanna thank Ben, but I wanna thank Ben as well. I wanna thank, and hopefully the fellows out there will recognize Dr. Safran for having put this together, this program, this past month and the month coming up. I know he's gonna be moderating. He's still gonna be on board, but there's gonna be some other moderators as we go in the next few weeks on a daily basis. So I hope you'll echo my sentiments. I know I do, and I know all the faculty do. Mark, you did an incredible job putting this together. I know you're not going anywhere, but I just wanna take the opportunity to say, what a great job this program has been for everybody. Thank you a lot. No, thank you guys. It's actually, it's just that all you guys are also so interested in helping teach the fellows, and I appreciate everybody just, no questions asked. You guys are willing to do it, and I figured everybody was tired of me asking questions, so I appreciate the tool being the Thursday guy, Steve being the Monday guy, Douglas is gonna be the Tuesday guy, I'm gonna be the Wednesday guy, and we'll split it up so that the fellows don't get sick of me any more than our fellows already are. So. Oh, I guess I'm asking questions on the hip over there, Mark. I'm very educated when I ask those questions, right? Well, you should be educated on the hip. I mean, again, it's the, the shoulder's just a really, really just plastic hip. So, you know, if you can do a hip, you can do a shoulder. It's not always the other way around. If you can do a shoulder, you can't always do a hip. The other way around, yeah. But thank you guys, and Steve, thanks. Ben, great job, as always. You know, you guys did great. I appreciate everybody's participation. Please be safe, have a great weekend. Next week's schedule is still on tap as had been previously planned. So Jeff Abrams on Monday, Dean Taylor on Tuesday, Rob LaPratt on Wednesday, and Shreen Oberam on Thursday. So thank you all very much. Have a great weekend, be safe, and we'll see you in May. Thanks, guys. Be safe, okay? Thanks, Ben. Thanks, Mark. Thank you. Thanks.

Multi-Institutional Sports Medicine Fellows Conference

rotator cuff diseases

advances in management

fashion trends in rotator cuff disease management

repair methods

effectiveness of surgery

physical therapy

PRP

fat content measurement

individualizing treatment plans