Instant, week late. So, I'll introduce you to my good friend Steve Brogmeier, associate professor at UVA and team position there. Steve is a tremendously good guy. We've gotten to know each other very well through committee work. He's been the education chair for AOSSM in the last few years. Very involved in the fellows course, which you guys all attended. He was one of the founding organizers of that and continues to do great things in the world of education. And gracious, this Puma and Chew mustache having time to us tonight to talk about management strategy for the irreparable rotator cuffs. So with that, I'll give it to Steve and say thanks and I look forward to it. All right, well, Jeff, thank you for the introduction. Mark, thank you for presenting this entire amazing webinar series. And it's my pleasure to be here. This has been an impressive educational experience for all involved, all of us, certainly all the fellows. So I'm gonna cover the topic that was on the title slide here. Here are my disclosures. I don't think that they will bias me, but I certainly would like to disclose them. And before we move along, I just want to do an emoji based kind of round of applause for Jeff and for Mark and for the guys who pulled this off. You know, this has really been an impressive thing. As Jeff mentioned, I'm the education chair for AOSSM. And I remember when Mark texted me about this, I think it was like on a Saturday night, which tells you what Mark likes to do on Saturday nights, apparently. But texted me with this idea and I was like, that sounds like a great idea. And in my mind, I was thinking, good luck. And by Monday, he had an agenda. And I think by Wednesday, he had all the faculty filled in and it was launched right after that. So a tremendous achievement during a very, very unusual time. And so let's all do a virtual round of applause to Mark, as well as Jeff and the other guys for putting something like this together as we're kind of nearing the, exactly. Take your moment, Mark. So anyways, let's talk about cough disease. You know, I know there's been some other talks on cough and I tried my best to not be redundant here, but you know, I think to kind of frame the discussion, you know, cause my topic is really the irreparable tear, but to frame the discussion, I think we need to talk, you know, about what rotator cuff disease really is. So, you know, this is basically, this is a, you know, rotator cuff problems. You know, you have traumatic rotator cuff tears. They do exist. We see them. They're kind of a different animal, but when you're talking about your, you know, the lion's share of the rotator cuff problems we treat, this is a disease of the aging. This is basically the wear parts in the human body. And so, you know, if you live long enough and you're active, expect to have rotator cuff problems. And, you know, whether those manifest symptomatically is really kind of the question that, you know, kind of the age old question with this problem. Understand that this is basically biologically compromised tissue. So what you're trying to do is you're trying to, if you come to surgery with these, you're trying to enact healing in a tissue that really just doesn't like to heal. And then those of us who see a lot of shoulder problems, we end up dealing with the revision. So patients who have had an attempt to prepare and it fails, you know, are those reparable? What are your options in those patients? And so, you know, when I see these patients in clinic, you want to look at the patient and figure out who the patient is. So their age, how healthy they are, some of their other kind of habits and comorbidities, what they like to do, what their occupation is. And then you want to look at the tears themselves and really each kind of specific circumstance deserves its own individualized management strategy. This algorithm we put together, I think it was a clinics and sports medicine a number of years ago. Bob Tajian kind of forward this along and I kind of like this algorithm because it's exactly how I approach things in clinic. But basically, if you look at these, really there's only this kind of middle group, this group two where surgery is going to be your first move. And that's going to be in patients with a true traumatic acute full thickness tear. And in particular tears in younger people. And then more chronic tears in a younger age group where there's kind of a good chance at intervening and kind of impacting the natural history of this problem. You may want to consider intervening in those patients. The rest of these patients really can be managed initially non-surgically. And there's a number of good studies out there. I think most of us are familiar with this data. And I think it's been presented in kind of in prior rotator cuff based talks, but it merits more praise because this is a really impressive study. If you look at it, these are a number of, you know, kind of high volume research guys. They all got together and they put together a group of nearly 500 patients that they basically convinced from a research standpoint to do PT initially and really follow how they did. And, you know, it's almost, from the standpoint of their outcomes, it's almost hard to believe, but really 75% of this group did not have surgery by two years post followup. So in that group, 75% PT essentially worked. And I think the thing for me was the key was that of those who failed therapy, they did it pretty early. So, you know, if you refer a patient for PT with this, you're going to want to see him back, you know, six weeks, eight weeks, 12 weeks. And you're going to feel pretty early on whether it's going to work or not. And if they do well, you can feel pretty good about the fact that this is a patient that may not end up needing surgery. And if they're not doing well, then that's a patient you should consider doing surgery to address their problems. And they found that patient expectations were a main generator of outcome, which we see across the spectrum of things. Norway is known for its level one studies. It's a very scientific medical community. And so there's some data from Norway. This is a study, kind of a slightly older study in 2014, where they did a similar thing, but they basically compared surgery with non-op treatment. And while the surgical patients had a slightly better scores, it was not, it didn't meet at least with their powering the threshold for clinical significance. So, you know, in reality, non-op treatment certainly has a big role in the setting of a reparable rotator cuff tear. And I'll talk a little bit more in a few minutes about the non-operative approach to somebody with an irreparable tear. Because in that patient group, there are certainly some strategies that we can use. So here's a case example. This is kind of the standard cuff case. You know, my partner Winston's on this call, so he can kind of verify that this is the kind of stuff that we see pretty commonly in our clinic. But this is the guy who comes in with, you know, well, maybe my shoulder's been bugging me for, I don't know, like four or five years, but I've just put up with it. And really they come in because they can't get any sleep. So over time, it becomes worse. They either lose function or their pain's bad at night and they lose sleep. And so now this guy's got this very chronic appearing tear. You got some muscle atrophy. You got some other features that are just really not, you know, kind of encouraging features. And so this is the guy that we see all the time. This to me looks like irreparable tear, but it's borderline, very retracted. You can see kind of a borderline tangent sign and some notable muscle atrophy. When you're thinking about doing a cuff repair, you got to understand the actual anatomy of the rotator cuff. So the way that the rotator cuff, you know, an intact rotator cuff attaches to the bone is it goes through these intermediate stages. So you have tendon and you have unmineralized fiber cartilage, mineralized fiber cartilage, and then bone. And so that's the transition. When you do a rotator cuff repair, what you end up is essentially a scar. So what happens is you have tendon, the scar tissue, so basically, you know, fibrous tissue, and then bone. And so it's really not a kind of a normal transition. So the best you can really hope for with our current rotator cuff strategies is to just kind of get the thing to scar back down, similar to your skin healing and scarring or in other areas of our body. When we do rotator cuff surgery, failures inevitably will occur. And based on the patient and the size of the tear, et cetera, you know, the failure rates are sadly kind of higher than we want them to be. And when you look at how these fail, most commonly, they're going to fail either early, due to mechanical failure, meaning too much, too early, or in the mid-time frame, somewhere between three and six months where it's a biologic issue, just a lack of healing. These re-tears really are pretty uncommon. You do see them, but it's a lower percentage, probably in the 10 to 20% of all recurrent injuries. And so the majority of these happen early. And when you see these patients and they're not doing well and you get imaging, the real question is, is kind of what do you do with this imaging? So obviously, the image on the upper right, pretty straightforward. This is retorn, this is not attached. You know, this is a failed repair. But what do you do with the image in the bottom right, where you see, you know, obviously the tendon's retracted a bit and you got this kind of amorphous looking tissue. You know, this is a patient who's maybe four or five months out from surgery. What are you going to do with that patient? Is that going to get any better? And if you go back in and reoperate, are you going to make it any better? So these kind of failed cuff problems are really challenging things. And a lot of studies suggest, perhaps, that patients actually do well, regardless of whether it heals or not. And I think, you know, there's some potential dogma that that might be the case. If you really look at studies, and this is a meta-analysis here from 2014, basically, the bottom line is, is patients do certainly better when their repair heals. And so, you know, in the end, if the patient's not doing well, certainly be suspicious that they're not doing well. And intact repair certainly leads to better outcomes. So when you're talking about a tear that actually is reparable, but is borderline, you know, these are circumstances when you're going to want to consider other options. And so, whether that's something that's ontogenous, like marrow stimulation, whether that's going to be a grafting type procedure, and I'll talk about that here momentarily, or whether that's kind of biologics in the future, but where the role in biologics in this circumstance are real. And I think that's something that, you know, really we're just touching the surface on, and probably a topic for another talk. But the biologic kind of stimulus to get to encourage healing here is a major thing. So here's our farmer. So this is the guy I showed you early on here with the chronic tear, retracted, some muscle atrophy, et cetera. You can see he tore his biceps when we took out the stump. He had some subscap changes. We repaired a subscap, and you can see this kind of chronic L-shaped tear, retracted, but mobilizable and fixable. And so when I fix these, what I like to do, so certainly you're going to get most of your healing from the bone. So you want to go ahead and get the bone prepared. Oftentimes I'll poke some holes here. I do believe in marrow stimulation, so I think poking holes here to stimulate some healing. Steve Feely at HSS, when I was a fellow there, did a lot of good research looking at this vascular agent and where the blood supply comes from in the setting of a rotator cuff repair. And very little of it comes from the actual cuff tendon itself. In fact, really a negligible amount. So it's either coming from the bursa, from bleeding around the cuff repair, or most of it's really coming up from the bone, either your anchor sites or from the perforation. So you can see we're putting in anchors. Here we are poking small holes to kind of access the marrow contents and try to stimulate a healing response. So you can see a really good way of trying to get this thing to heal. I like doing these hybrid repairs where I mix in elements of a single row and double row repair, where you're kind of doing more of a single row repair to not over-lateralize your repair, and then backing it up with double row. There's some good data that suggests that double row repairs are better from a healing standpoint in larger tears. But the big challenge is it does have the ability to over-lateralize, pull the tendon further laterally. So if you fix it with a single row and then you back it up with these kind of retention suture double row repair, I think that's a good way to deal with that chronic tear that I just showed you. This is my typical post-op management program. Sling strictly for six weeks. You gotta go slow with these patients, these bigger tears in particular. And so really, you're just looking to make sure they don't get stiff. So some range of motion progression, all passive for six weeks, then some active assist and active from week six to week 12, really limiting any stress to the repair until about 12 weeks out to limit that kind of structural failure. The idea is to get motion back definitively at three to four months, but not three to four weeks. You wanna go incrementally with these patients and a strength progression from there. You don't need to go fast. And most patients, you're really not letting them start activities until at least four months. And certainly six months would be a kind of a reasonable kind of mid range, not even a conservative timeframe to let them get back to full activities. I mentioned there's data out there in marrow stimulation. So you can see these are a couple of studies really actually showed pretty good benefit. This is a slide I borrowed from Brian Cole, but it's a good study to kind of show a good slide that shows that there's good data out there to suggest that this process is a good thing to do. When you're going through the procedure of repairing a rotator cuff, here are some of the tenants that I like to really keep in mind as I'm doing them. So number one, don't waste time, move along, limit swelling, improve visualization, make sure you're efficient during surgery, really be thoughtful about how you're taking care of things in order. So I normally get into the joint, deal with anything in the joint, including the subscap, then biceps, then cuff. If I'm doing an open subpec biceps, I'll do that last. And you wanna really move along so that you're really not kind of limiting your ability to kind of repair in an anatomic way. As I said, to breathe the tuberosity, invent it, restore the anatomy, think about these almost like a fracture case or any type of tissue repair reconstruction case. You gotta think about the tear and what the geometry of that tear is and repair it in as close as you can in anatomic way. And really you wanna be thoughtful about multiple sutures and good, strong suture tendon interface because that's where you're gonna see failure in most cases. And then again, don't lateralize. So moving on to maybe some more challenging cases, you can see this with clearly some loss in tendon substance. It's a very shortened tendency of tendon loss in this guy, maybe a little bit of early arthrosis, but it's a young patient. So what do you do with this? Good muscle, so perhaps it's repairable, but this is one where maybe you have concerns about irreparability. Here's another patient. X-rays look okay, no migration north, very weak patient. He had already had a repair done earlier. And now you have one of these type two failures where basically the tear occurs not at the tendon bone interface, but more medially. These are pretty tricky. And so these are cases where I consider doing some sort of augment. And there's a bunch of different techniques out there in what you do. I'll show you what I use or some of the different options that I will consider in my patients. But this is definitely an evolving area. There's a number of different substrates out there, whether they're allograft or xenograft or different synthetic options. You can see the rotation medical patch that is a very small, thin xenograft option. Most of the time when I do these, I'll utilize some level of a dermal, so an acellular human dermal allografts. You can see here's a case example of that. So you can see a really, really sizable tear. You can see the cuff tissue to the left and the kind of the naked tuberosity here. So I approach it the same way. So you wanna repair the infra first, get this up in that margin. You can see an anchor place there with some sutures pulling the infra back up, which was repairable. And again, kind of a hybrid type repair where you pull what's left of the tendon up essentially to the medial footprint. So you're getting the tendon repaired back to the patient. So I think it's important when you're thinking about a grafting procedure, you don't wanna use a bridging graft. It's more important that you wanna actually get the patient's tissue back if at all possible. And in this case, if you look here, you can see the muscle tendon junction here if you guys can see my cursor or my mouse, but you can see the muscles lateralized a bit. So this is lateralizing some, but I think the benefits of that gets this tissue back there and hopefully get some native tissue healing. And then when I'm doing a grafting procedure, you can kind of basically then lay the graft on top and integrate it essentially into your repair. So you can see, this is what it looks like on the outside. And then this is what it looks like when you're done to help reinforce your repair. And sometimes you can actually then introduce a biologic substrate, whether it be PRP or in my circumstances, a lot of times I'll use a bone marrow aspirated concentrate. And I think I got a case of that here. So here's a video, I'll kind of go fast through this, but this is a video that I think I presented at AOSSM a couple of years ago, but here's that exact case. You can kind of see the steps. You know, this is a surgery that's very, you know, it's feasible to do. You can see again, some tendon loss here, but this thing is mobile. It'll come back over. You know, again, you want to be efficient. So you deal with the subscap first if it's torn. And I can't recall, you can kind of see it off there in the distance. I can't recall if we had to repair the subscap. It looks like we didn't in this guy. So you want to clean off the tuberosity, remove any of this kind of this tissue that will kind of aggregate there and limit healing. You can see that first anchor replaced. This is a double loaded anchor. You know, sometimes I'll even do a triple loaded anchor and kind of load another suture in there, but you repair the infra back. And you can see, this is kind of like a reverse L-shaped tear. So you can see, we're kind of marching up the infra to fix it. And then in a moment, you'll see that we're going to take the supra and we're going to repair it both laterally, but also in an anterior to posterior direction. You'll see the apex of this tendon is actually kind of is pulled anteriorly. And so that's what allows us to repair this. A lot of these cuff tears that we'll say are kind of quote unquote irreparable, actually are repairable if you use the right approach. So you can see, this is a highly retracted tear, but the tissue will come over if you repair it the correct way. So you can see, we're bringing this slightly from anterior to posterior to try to get this back. This is all supraspinatus. So you can see there's a cleavage component or a vertical component that goes along in between the infra and the supra. So this is how you kind of bring it back to the tuberosity and kind of get this thing docked. And so now you can see we're getting our sutures kind of mobilized out. And you want to be organized. You want to make sure that your sutures don't get twisted and don't get loops. You can see we put this under tension. We've made some measurements to figure out what we're going to do with our graft. The graft is a bilayer graft, meaning that there's a layer that should go down on top of the tissue where the tissue will grow into it. And then there's a layer that's better on the top. It actually, in my opinion, actually limits adhesions and allows for almost a kind of protection of your repair to some degree. And so once we've made our measurements, we'll kind of craft our graft. I've marked a T on the top to kind of make sure that I don't get confused on how to orient it, you know, top versus bottom. We'll set it up with a couple of clamps, bring it over into the field, and then we'll begin to pass sutures. And the sutures are passed based on some of the measurements and observations you make inside the joint. And you'll see, we kind of go through and sequentially pass these sutures through the graft and get everything in place. So I'll fast forward here. Actually, let me go back just a little bit. So once the sutures are all passed, then you introduce the graft into the space. And you can see here kind of in real time, we're kind of pushing it into place. And this is the part where you got to get kind of organized and get the graft where you want it. You want to make sure you have really good visualization, make sure whoever's helping you kind of really knows what you're trying to accomplish here and can help you carry it out. And then you start tying down and basically start posterior, then anterior, and then in this middle portion to get the graft down and in place. And then once you have these, and you want to be thoughtful about suture management in these cases, you certainly don't want things to overlap, kind of keep things organized. Oops, sorry about that. So we'll go back to the case or to the video here where I left off. You can see, we're kind of getting everything kind of pulled over. And you go to your lateral row, you can see we've been to the tuberosity in this guy and get to lateral row, fix it. And then you'll see here, once we're done, you can use the preloaded sutures to kind of then tension the actual patch itself. I do think it's important to put the graft under tension itself. So you'll see, we'll tie this down now and that gets the actual allograft down. And so I like to put it on top. I do think that there's certain cases where I haven't done it yet, but I do think there may be some cases where you kind of do an SCR. We'll talk about that shortly, but an SCR and then repair the cup on top of it. And so there may be a role in certain circumstances for doing this in reverse, where you basically put your graft inferior to your tendon repair. But in this case, I think what you can do is you can repair the patient's tissue and then create this kind of augmented repair, plus or minus a biologic and get you a good repair construct. Lots of data out there actually on this. Most of it is actually pretty good, high level data. Steve Snyder's initial looking at the graft jacket, Alan Barber's study. Alison Toth has some great data on dermal tissue allograft as well as xenograft. So there's good data out there that really does show that this is a great option, I think, in the right patient. We did a study actually at our institution. I'll show you, this is a kind of a demonstrative case. This is a 20, or excuse me, a 54 year old. This guy's a tennis coach and this is his dominant arm. You can see this gigantic cyst and this greater tuberosity. So in this guy, we actually use a different type of graft. This is a synthetic type graft that resorbs over time. You can see similar type of tear configuration to the video I just showed you in a similar repair. We bone grafted his enthesial cyst and repaired it. You can see this how it looked afterwards. You can see what his range of motion. Now this is about a year out. So it takes these guys a while to get better, but you can see he was able to get back to actually playing tennis, which was surprising, quite honestly. And during the time in between his surgery and when he was able, cleared by me to play tennis, he actually was an instructor with his left arm. So, you know, pretty facile guy, pretty interesting story from the standpoint of staying, you know, working. We actually looked at this scaffold and published our data. This is from about five years ago. This was a Tournier product. It's called BioFiber. And you can see, this is what it looked like. We got ultrasound to look at healing, see the tuberosity down here, patient's native cuff. And you can see how this graft sits on top and incorporated quite well. In fact, under ultrasound at six months, we had about 90% integrity and about 12 months, 85. There's a pretty good, you know, given these are large tears, a pretty good success rate with a graft type procedure. So we were pretty happy with that data. So kind of finishing this off, when do I consider an augment? Larger tears, especially in younger, highly active people where you really want to make sure your tear is reinforced. If you have tendon loss or poor tissue or these medial failures and in revision cases. And so those are the types of times that I'm really considering doing some sort of augmentation procedure. I'm not going to really go down the rabbit hole of cell-based strategies too much, because I think it's outside of my topic, but PRP and MSCs, there is good data out there. The data with PRP and cuff repair is really not all that encouraging. In fact, Scott Rodeo's study was being, he was collecting some of these patients when I was there as a fellow. And really, they actually found a potential negative effect with a particular type of PRP. The Randelli study was the only one that really showed any benefit. And that was really just from the standpoint of pain and early function. So really, over the longer term, really there's not much out there that suggests PRP augmentation of cuff repair is a great option. BMAC is a different thing. And there's a bunch of different MSC strategies. I'll show you a case where I, you know, and I use this, I would say not uncommonly, probably 10 to 12 cases a year, something along those lines. But this is a young guy. He was parachuting. The parachute didn't open completely. And so he came down. He had a traumatic, obviously a highly traumatic cuff tear that was missed because he also had an acetabular fracture and some other things that were managed. And this is a really, really high demand guy. And so he comes in about, I don't know, six, eight months down the line. And he's got this tear, which is kind of your chronically retracted acute tear. And not a great circumstance. He was also really stiff. So I think many of us have seen the study, Hernigou's study from 2014, a really well done. It's a level two study, but really suggested that bone marrow aspirated concentrate would be a good option to augment repairs. And so it is something that I've started to use. We use the Arthrex system in our place. But there's a number of different options out there to get you marrow, concentrated marrow aspirate. I'd recommend you take it from the iliac crest. There's pretty good data to suggest that's where you're going to get your highest yield. It's certainly a little easier, obviously, to take it from the tuberosity. But especially in patients with rotator cuff tears, there does not seem to be the same level of yield of mesenchymal cells from the tuberosity. So what we'll do is we'll prep and drape the hip, as you can see here. And we'll do an aspirate from the hip. You need to get about 60 cc's and pull it out. And then you spin it down on the back table. And then we'll go ahead and prep and drape and do the case. You can see in this guy, fairly simple repair. Pulled it down similar. And, you know, we vented the tuberosity as well. We did a hybrid type repair. Laid a patch on top. And then you can see you can just inject your BMAC, your cells, from underneath. And really the patch acts as almost like a wick or a trap to keep these cells in place. It's a nice way of doing it. And this guy actually had a great result. You can see this is actually him lifting his arm up. And you can't really tell which one we fixed kind of post-op here. It's actually the left side. He's got a little bit, if you really look closely, he rotates pretty close but not perfect. But he was really happy with his result. And he was able to get back to work. He's done well with his hip as well. So let's talk about some of the options when you can't fix the cuff. And obviously this is the topic that I was tasked with here. And it's an interesting topic because there are options. And the key is just to figure out when to use what option. And to not over-indicate, not under-indicate, and try to do right by your patients. So, you know, everybody likes these commercials that, you know, ah, he's okay. The outcomes of these, you don't want them to just be okay. You want to be really thoughtful about when you're indicating these patients to these types of procedures and what's going to work well. And this is a non-comprehensive list. But really, in my mind, kind of what I'm thinking about when I'm approaching these patients, you know, as different options. So I mentioned early on, from the standpoint of physical therapy, in somebody with an irreparable rotator cuff tear, especially somebody with clear functional compromise, so pseudoparalysis. There are, there are clear PT options that work well in these patients. And I refer you to this paper that's not new from Ofer Levy and his group in Reading in the UK. And really, the focus is on re-education of the remaining cuffs of rotational strengthening and in deltoid strengthening. So what you're trying to do is basically allow both the anterior deltoid as well as to some degree the lateral and posterior deltoid to assist the rotator cuff in functioning in somebody who's essentially rotator cuff deficient. And if approached the correct way, you can get a lot of patients actually significant improvement, both from a functional standpoint and from a pain standpoint. So, you know, for these patients, especially in patients who maybe aren't great surgical candidates, and people who are young and you don't have a great option for them, or people who are older and a little bit more frail, this is going to be your initial approach in almost all of them. And so don't forget physical therapy. But that being said, if that fails or if you think it's time to operate, then there's an algorithm that you can follow. And I borrowed this algorithm from somebody else. And I like it mostly because it cascades down to the potential for a long, painful conversation, which you don't really see that listed in an algorithm very commonly. So I thought that's kind of appropriate but real. But basically, you have a massive irreparable cuff tear. You know, if you have arthritis, you got to jump towards an arthroplasty. If you don't, then you got to think about is the patient high demand or low demand. If they're high demand, then you move over. And if they're pseudo-paralytic, then you're probably best served again with an arthroplasty. If they're not, then you can consider a partial repair or just a debridement and a biceps procedure. If they're a higher demand patient, those aren't great options in those patients. And so your options are, you know, if they're pseudo-paralytic and they have instability, then you have that painful conversation. Or if they don't, then you have that painful conversation. If they do, then again, you're thinking arthroplasty probably in that patient. But if they're not pseudo-paralytic and they have pain or weakness, then you have options. If it's more pain, those are the patients where I think SCR is going to be your best option. My personal experience with SCR is if you have somebody who's really weak, whether it's true pseudoparalysis or even pseudoparesis, an SCR is maybe not as predictable an option in that patient group. And then tendon transfer really fits. And it's an uncommon patient in my practice. But there are patients where, you know, in a younger kind of high demand patient who's weak, a tendon transfer is going to be a great option there. And so we'll talk about those options here shortly. But let's show this case example. So this is a young patient. It's a 42-year-old, you know, very normal. She works. She's a very, very high demand patient. Does all this CrossFit stuff. She's pretty jacked. And she comes in and she kind of lives, she doesn't live near to us. She comes from about a two-hour distance. Comes in after being managed essentially non-operatively for a traumatic cuff tear. So she had this CrossFit injury 18 months ago. She was doing some sort of deadlift into burpee sequence with CrossFit. And she felt something give in her shoulder. Immediate pain and weakness. Was managed with PT for about five months. Had a ton of injections. Sent to be seen for her neck to see if it was the neck causing a problem. Eventually, finally, she came into our office with this MRI, where you can see some biceps issues. You can see an irreparable supra with some tendon loss. The tendon's still attached up here to the tuberosity. And what's left of it is a very, very small amount. And then all of this muscular atrophy. So this is your worst case scenario. You're a young, high-demand person. Dominant arm. And you've really lost your opportunity here. So we're all familiar, I think, with Mahata's work initially with superior capsular reconstruction. His procedure involved using IT band allograft. So it's a different procedure. It's an open procedure. Harvest a fasciolata. Normally, he takes the fasciolata and he doubles it or triples it to create a really, really robust graft. And he uses it essentially as a bridge between the superior glenoid and the superior greater tuberosity in the setting of an intact anterior and posterior cuff. And when you look at his data, it's really, really impressive. You know, to the point where those of us who treat patients like this, it's almost impressive enough that it makes you really wonder how this is possible, right? So when you see these patients, to get this type of outcomes from the standpoint of frequency is just an amazing thing. So there was this huge level of interest, like, gosh, maybe this is the solution for these patients when we see them. So the patient like I showed you here. So you can see ASES scores north of 90, forward elevation increase of 84 to 148, and intact repairs and grafts at upwards of 80%. I mean, these are great numbers. And so as we know, our industry folks really latched onto this. And it's something that became a really hot topic for a period of three or four years. And, you know, all of us were looking at this as an option in our patients. And there was a lot of interest in SCR. So where are we with this operation now? I've oscillated back and forth. Initially, I was a little bit skeptical, but I had enough patients that I felt that I would try it, and I tried it in a number of patients. And my initial results were favorable in a subset and really not favorable in another subset. So I backed off a little bit. And then over time, as I've kind of refined my indications, I kind of found where it fit in my practice. So here's what I use. And these are fairly rigid indications. So young patients, and young is in rabbit ears here because, you know, young is not necessarily your age, but your level of activity and your level of demand. We're not talking about 70-year-olds. You're probably talking about people in their 40s and 50s and early 60s and people who are highly active. They're motivated patients. They cannot have really any arthropathy at all. So they can't have any chondral damage whatsoever. In my opinion, this does better with the subscap intact. So if the subscap is, you know, if the upper edge is torn, I'll fix that and we can do an SCR. But if they have a true subscap tear, I think an SCR is a really tough ask in that circumstance. So I really, really think twice about doing SCR in the setting of a subscap that I have to repair. They have to have a repairable infraspinatus or posterior cuff. So either it's intact or it's really very fixable and there's no real kind of muscular atrophy. I don't like to use this in work comp patients because, again, I think you're asking a lot of it to get somebody back to a high labor job. And the patients have to be pretty straightforward. They have to be motivated. And I put in here no oddities. But basically, you don't want to use it in quirky patients because they just don't do well with this operation. So be really thoughtful about how you indicate this. The other thing that's improved, I think, over the years, you know, it's not been that many years, but over the probably five to six years we've been doing these SCR procedures, is understanding how to carry out the procedure. And, you know, what we're doing in the U.S. is different than what Mahata is doing. We're not doing fascial autograft. It's an allograft that we're using to try to kind of mimic this procedure. So number one, you got to get everything prepped. You need to be able to see well. You can see here we have three anchors on the glenoid side, which you really want to do. You have kind of good purchase on the humeral side. And then you have to be really thoughtful about measurement and understanding kind of what type of graft, the shape and the dimensions and where you place your suture so you can tension your graft appropriately. There are numerous options for glenoid fixation. I've gone to using the knotless option because I do think it's more facile from an operative standpoint. It used to be that the recommendation was to kind of link your sutures between these anchors and kind of do the shimmying down technique. And it was easier to get the graft into the joint, but it's definitely not an anatomic technique. So I do three points of fixation on the glenoid, knotless or knotted suture tack or, you know, kind of glenoid-based anchors to fix it. You can see here on the humeral side as well. So you can see here's the glenoid side. On the humeral side, you want to really make sure you get your graft kind of positioned anatomically, and you want to tension it perfectly. So when you're measuring, in particular, medial to lateral, you got to be really thoughtful about how you measure these. And so you want to really make sure you're trying to be as anatomic as possible. I showed you the photos of kind of introducing the graft for an augment procedure. This is how you do it for an SCR. And again, you want to be really thoughtful about staying organized. That's kind of the hardest part of the case is getting things organized externally and then getting the graft position into the joint. So here's what we do to get that in there. And so this is to the left before, and this is after. This is actually, this is my partner Brian Warner's slide. So this is one of his cases. But you can see how this graft, once you get it positioned, really kind of covers up the tuberosity well, and you can see how it tensions out nicely. And so, and then I do think it's helpful to try to use whatever cup tissue you have left. So you do posterior repair, so side to side sutures there. And then often I'll do an anterior repair as well. A lot of times you do have some level of rotator interval type tissue that you can repair it to. I don't tend to repair it to the upper edge of the subscap unless I'm doing it just on the lateral kind of aspect of it. But if there's rotator interval tissue there to kind of hold the graft out on the anterior side, I do think that's helpful as well. So you can see here, this is kind of before to the left and after to the right and then the video. So this is this patient. You can see we used what was left of her cup tissue to pull over and kind of cover up the graft on the glenoid. We repaired it anteriorly and posteriorly, and then we tensioned it well. And you can see we're moving the arm around, pushing the arm north. In a second I'll put in a probe here, and you can see how kind of, there's pretty good tension. Obviously you want this thing to hold in place and heal. So there's a bit of a gestalt as far as how you tension this. And you can see you want this kind of trampoline effect when you push on it. So it really kind of holds the arm down and the graft is under tension and hopefully heals. You want to use a thick graft. So this is acellular dermis. And when I'm doing an augment, I'm doing a graft that's about 1.5 to 2 millimeters in thickness. I want this to be about 3 to 3.5 millimeters in thickness. So this is a really, really thick piece of tissue. Not as thick as mahatas, but thick. Post-op management for these are critical as well. You want to do a slow, deliberate approach. No reason to rush. So it's similar to the approach I showed you with these massive cuff tears. So this video is actually this patient. You can see she's pretty jacked. And so this is how she moved her arm afterwards. She felt good. You know, if you asked her, she'd tell you that it's not quite as strong as her other side. But from the standpoint of range of motion and getting back to function, she actually had a really good outcome. So with the right patient and the right circumstance, an STR is a really, really good operation. So this is an operation that I do think has been a huge addition to the toolbox. But you've got to be really, really thoughtful about how to carry it out. And really, more importantly, when to indicate it and how to rehab it afterwards. There's some good data out there looking at outcomes. There's some emerging data. So there's data from mahata, both two and five-year outcomes. Low graft failure rate at five years, 10%. Again, just tremendous outcomes that he's presenting from his cohort. I don't know that we're seeing that with ours, but we're seeing pretty good outcomes. So there's biomechanical outcomes here you can see. And then clinical outcomes are kind of coming. So you can see these are some US-based studies, kind of preliminary results. Maybe not quite as good as mahata's outcomes. But again, if you find the right patient population, you can get a good outcome with an STR operation. So again, I think STR is here to stay. Here's from the SOS data. So, you know, really outcomes, scores are oncoming. I think STR is to stay. And it is something that we should use. But again, you just got to be thoughtful about when to use it. This is a great article with Tony Romeo, kind of looking at both the indication techniques and the outcomes to kind of summarize this if you guys want to kind of read more about this. So let's move on to another option. And some of these slides are courtesy of some of my colleagues. This slide's from Anand Murthy. This is his case. And so this is a tendon transfer case. You know, tendon transfer is something that I'll use from time to time. But I don't have a huge volume of these in my personal practice. There are patients out there that I think are good fits for this. But you'll see them kind of more often as they get referred in. But this is a 54-year-old guy, ATV accident, right shoulder, has had prior attempted repairs. Comes in with both pain and limited function. You know, really, really poor function in this person. This guy's a manual laborer, so it kind of fits that bill. And you can see here, it's a younger guy with a really bad functioning shoulder, maybe a little bit of early arthritis, but, you know, nothing too bad there. And here you can see his range of motion, right? So active external rotation's pretty bad, forward elevation's pretty bad. But he's not pseudoparalytic. And then you can see very little cuff to work with. In particular, the posterior superior cuff. So if you're doing a tendon transfer for an irreparable subscap, normally we do a pec major transfer in that circumstance. If you do a tendon repair for the posterior superior cuff, there's a couple of options I'll show you. So what are the indications for tendon transfer? Irreparable posterior superior rotator cuff tear, severe pain. You don't want to do these in patients who have true escape or pseudoparesis. They need to have an intact subscap. And so, you know, the question is whether you can repair the subscap and do a tendon transfer again. It's a pretty big ask. But some would say you can get away with that. In my experience, I think that's probably not going to be that predictable. And then the relative indications, you want to do these in younger laborer type of patients, right? If you're seeing a 70-year-old with this type of stuff, you're going to think this is a patient who's got probably a more predictable outcome with a reverse arthroplasty. So Christian Gerber is probably the best data out there on latissimus dorsi tendon transfer. And this is a good study from 2013 from Gerber's group on lat dorsi. And, you know, he gets really good outcomes. Obviously, he knows what he's doing with these tendon transfers. It is not an easy operation to carry out. The latissimus is a very, very thin tendon. And you can take it either on its own or with the Terry's major. Actually, getting it in position and repairing it is not as easy as this schematic makes it look. And I will tell you, the hardest part is really the rehab. So this is a long and kind of arduous rehab. You got to get it to heal. You got to make sure they don't get stiff. You got to work on periscopular rehab. And then you got to do a lot of muscle reeducation to try to teach the latissimus to try to mimic some of the contributions of the posterior superior cuff. So we're talking a year to 18 months of rehab to get an outcome with these patients. And so there's a bunch of studies out there. There's varied techniques. Some people add some graft to augment or graft to kind of extend the lat up into position. It's not very good for pseudoparalysis. Satisfaction is okay, but not great. When you look at a constant score, if it's around 75, that's a mediocre outcome. So those are patients, you know, that maybe had a pretty bad constant score to start. But really, to get a 75, most of us are not going to be that happy with that number. It may work great in Switzerland or elsewhere. But in the U.S., I think the outcomes sometimes are a bit checkered. And in my experience with lat transfer, it's been a bit plus minus, quite honestly. I think a better option that's emerged recently is the lower trapezius transfer. And this has been mostly popularized by Basim Elassan at the Mayo Clinic. I personally don't have any actual experience with this operation. I haven't done one. We have a colleague here at UVA who trained. He's actually one of our plastic surgery hand faculty. But he trained up at the Mayo Clinic and worked with Basim. So he does these from time to time here. And so if I have a patient that I think is a good fit here, I'll refer them to him most of the time. The rationale for the lower trap is that it's an in-phase muscle. So the latissimus is not an in-phase muscle for the cuff, right? The latissimus is an AD ductor and an extender, right? And so you want something that's going to be an external rotator and something in plane from the standpoint of the posterior cuff. So that's where the lower trap comes into play. This is the open technique. So basically, it's two incisions, one for the harvest and the second for the reattachment. So that's the open technique here. From the standpoint of carrying this out, again, these are pearls from Anand and from Basim and from Lisa Gallatz and the people who do these more commonly. So first of all, know that the anatomy, the nerve is located between the middle and the lower trap, and you certainly don't want to get the nerve as you're doing this operation or else you're not going to really get a good tendon transfer. The incisions in line with the shirt sleeve, you want to have a proper plane for your tunnel. So you want to get your harvest in and you want to really plane kind of deep and over the rotator cuff. So you're kind of coming in above the supra and infra to kind of get this thing in the right plane and get it into subacromial space. You actually extend these with a graft. So obviously, the lower trap is not going to reach all the way around and attach. You use either an Achilles or some people will use other grafts. I'll show you a couple of techniques in a second to kind of show how you extend these. And you want to be really thoughtful in people with poor bone quality and poor tissue. So here's a case. You can see the lower, this is the lower trapezius harvested. It's a short tendon. It's obviously not going to reach over. So in this case, they're using an Achilles allograft to extend it. So you harvest your graft, you measure it out, you fix it to the trapezius and then you tunnel it and you bring it in underneath and you repair it to the tuberosity. And here you can see it's tunneling in. And so you can see here the position. You want to position the arm in external rotation. You actually want to put this in tight, the idea being to tension the graft initially and over time the muscle will then kind of build and it allows them to kind of pull it back. Here's another case. This is a 53-year-old male. And this is a slide courtesy of George Athwal in Canada. And so you can see again, massive irreparable cuff tear, some atrophy both posteriorly and superiorly, ER with a lag sign. So this is somebody with really a posterior component. And so here's a good video that George put together of an arthroscopic assisted lower trapezius transfer. And in this case, they're going to use an autographed semitendinosus. And so you can see here, here's the surgical anatomy, the incision. You can see here, you kind of get down and the trap is going to be your first layer. You want to be cautious with the neurovascular structures and isolate out the lower portion of the trapezius muscle here. So you can see there's the muscle. In a second, you'll see that muscle harvested. You can see in Canada, they like to use a blowtorch here with the bovie. So here you can see a pretty robust looking muscle once you have it. And so you've isolated this out and now you're ready to, so here's your knee harvest. You can see kind of a typical semitendinosus harvest. They don't use much in the way of allograft in Canada. And so autographed is kind of their preferred option here. But you can see basically you docked one end of the graft and you kind of whip stitch it into the tendon of the lat, excuse me, not the lat, the lower trapezius. Good solid repair. And then you move to the scope part of the procedure. So you tunnel it in. In a second here, you'll see George. And so you've got to get everything prepped in subchromial space. You've got this irreparable cuff tear. Just for the purposes of time, I'll show how he preps this out. And so what he does is he kind of gets what tissue is left and you can kind of do a partial repair of it. And then you get ready for your replacement. So you'll see here in a second, he targets. And he'll skewer in a second with guide pin from posterior to anterior. You can see this guide pin is in and in place. And then you make a reaming trough. So for those of us who do ACL surgery, this is going to seem very reminiscent. And then in a second, you'll see he'll bring the graft in with a loop. So this is going to be basically a kind of an endo button type fixation. So you can see the button here. And that's going to be pulled through anteriorly. Flip and lock in right here. There's the loop, there's the button coming in, and you can see it's going to be double looped, kind of like a hamstring ACL, and you'll see they'll bring it in here. We'll fast forward George's video, but you can see the double tendon going in, flip the loop. Now you have it in place, and then you can tension now. So you bring the arm in external rotation, and you can tension it, and then you suture it back, and now you have your tensioned tendon transfer. So historically, latissimus transfer has been our go-to. There's still probably a role for that in some surgeon's hand. It's not something that I tend to like to use. If I'm doing a posterior superior cuff, I think trapezius transfer, the lower trap transfer is probably a better option. The indications essentially are going to be in patients where you normally would do a reverse, but it's contraindicated due to either patient age or level of activity or things of that nature. For subscap, as I said, you're going to do a pec transfer. It's a different option for subscap. So to close, I really wanted to show one kind of emerging option, and then just a couple of quick slides on arthroplasty. So these are slides courtesy of Joe Vood. Many of you may be familiar with this balloon, arthroplasty subacromial space balloon. So this is something that's coming, right? It's not FDA approved, so this is not something you can use currently. There was an investigational device evaluation that was carried out, and Joe was one of the sites at the Jefferson, with the Jefferson Group, so he shared these slides with me to kind of show you guys. So it's available in Europe, but it's not available in the USA yet. The idea, I believe, is actually now done. It's certainly closed for enrollment, but I think it's done. And so this may be coming out soon. So the indications outside of the U.S. are massive irreparable tear with subscap involvement. Sometimes people are using double loomed balloons in this circumstance. Also, and sometimes in Europe, they're actually using these to augment kind of a dicey rotator cuff repair. So it's a repairable repair, whether you're not that happy with you put a balloon on top of it to protect your repair. So, you know, there may be some additional options outside of the irreparable tear. You can see here, there's some clinical studies out there, mostly European in nature. The results have been largely encouraging. So this is a resorbable implant. So you put it in, and over about three to four months, it actually disappears. And it incites kind of a fibrocytic response and allows kind of correction of the cephalad migration, and in many cases, the pseudoparalysis that you see in that circumstance. So here's a case that Joe shared. This is a 63-year-old mason. You don't see a lot of masons these days, with a history of a right rotator cuff tear. It was treated operatively before, and he failed that, increasing pain over six months. He's had conservative options. You can see here an irreparable cuff tear, really no superior or posterior cuff to speak of. Subscap is actually largely intact in this guy. So here's what it looks like inside the joint. And then here's a video to kind of show how this thing is positioned and placed. So you can see, you got to clear out the subacrobial space, and then the balloon is introduced. They have this introducer here. You can see that you kind of push into place. You know, talking with the surgeons who have done these procedures, it's actually technically, I think, very easy, and it's very quick. You know, these cases don't take long normally. It's about a 20 to 30-minute procedure just to deploy and position this balloon and then inflate it, and then you're out. So you can see, this is the balloon being put into place. So it comes in kind of pre-rolled, essentially, and then as you inflate it, it kind of, you know, almost like an inflatable mattress. It's going to kind of roll out and roll into position. So you see in a second, injection of saline into the balloon, and over time, this balloon's going to kind of expand and kind of fill this subacromial space, press the humerus inferiorly, and create a buffer to limit the impaction of the upper edge of the tuberosity onto the acromion, and hopefully over time, create some level of both pain release, increase in function, and buy this patient some time. One thing you can see here is the biceps tendon's actually intact in this patient. I asked Joe this question when he showed me this video, but in many cases, they actually leave the biceps intact, which I wouldn't have done myself, but quite honestly, it sounds like they've seen pretty good results by doing so. But you can see what this procedure looks like. So this is a new option. It's, again, not out yet. It may be coming down the pike soon. The initial results have been encouraging, and so the question is where does this fit in? And this may fit in in the same bucket with SCR or with tendon transfer, and so another option in the toolbox that you can consider kind of based on the patient and kind of who the patient is. This might be a better option for maybe kind of lower demand, older people. It may be a good bridge, you know, quite honestly, maybe to arthroplasty in the future. It may buy you out of an arthroplasty, but again, another option to use. Finally and briefly, reverse TSA, I'm not going to go kind of too far down the path of shoulder arthroplasty, but this is going to be your option. In the older population, people who have poor protoplasm where you really just think nothing else is going to work other than a replacement, and then obviously anybody with some level of joint arthrosis. Reverse has come a long way, obviously a very predictable operation from a pain relief standpoint, functional outcomes have done actually very well in the right patient population, and then longevity, you know, initially we were very concerned about the high complication rate and longevity, but we've really come a long way with this operation, so it's a good option. So here's a patient of mine, 58-year-old teacher. You can see all the various different anchors that people have tried over the years. You can see here, acetabularization, et cetera. She's clearly not going to be a patient where another rotator cuff procedure is an option. You can see a little bit, you can see this spur down here, she's developing some arthritis, so maybe not a great option for an SCR, and you know, again, tendon transfer may be not so good with arthrosis. So this is a good option for a reverse. One thing I will quickly tout, and I do, I am a consultant for the company that has this technology, so I will, you know, obviously declare that conflict, but when you're doing arthroplasty, do consider planning your cases, and this is a navigation option. So you can see, this is one of these patients that kind of has a ton of arthritis, but also some cuff involvement, so here's a navigated cuff. You can see very little glenoid bone stock, and you can see with the use of intraoperative navigation to be able to really utilize what you have here to kind of optimize your component positioning, and hopefully over time, your patient outcome. So this is that case I was just showing here using intraoperative navigation, so something to consider. When you look at outcomes of reverse patient satisfaction and pain relief greater than 90%, functional outcome can be a little bit less predictable from one patient to the next, but quite honestly, most of them do pretty well, and they're pretty happy with it, and the longevity is probably better than we thought. When you look at outcomes, and you try to quantify these from an evidence-based standpoint, the numbers are okay, but when you talk about patient satisfaction, most patients are highly satisfied with their outcome unless they run into an issue with a complication. Return to sports, for the sports medicine fellows here, patients are able to get back to a fair amount, but this is not an anatomic arthroplasty. As you can see here, you know, the return to sport, you know, in this particular, and this is Joe Zuckerman's group, you can see it's a high number. It's about, you know, in the ballpark of 50%, but when you look at, you know, resurfacing or hemi or anatomic total shoulder, not the same. Larry Galata really looked at this closely, and really, in the end, the patients were able to get back to what they did before, by and large, and did pretty well. So, you can see things like swimming or golf, most of them were able to get back to a high level of activity, so reverse is a good option. So, summary comments on reverse, predictable pain relief, many return to high level of activity after reverse, and you can be comfortable with that. I think the keys are really managing the posterior cuff. If they have a lag, or if they really are deficient posteriorly, you may want to be, consideration given to using a concomitant latissimus transfer. In this patient population, a lat transfer is something that I'll use in concert with a reverse if they have, you know, true posterior cuff insufficiency. That's a good option in a higher demand patient, and be thoughtful about kind of all the typical things with reverse. I'm not going to kind of go too far with that. That's a kind of a conversation for another day. So, some final comments to tie this up, and then we'll move to some question and answer. Number one, understand the indications for rotator cuff repair. Non-op management works in many patients, and many of these, quote, irreparable cuffs are actually pretty repairable. So, you want to be thoughtful about, you know, when can I actually repair this? That's going to be your best option for any of these patients. If you can repair their cuff and get it to heal, that's going to do better than any of these other options that I went through. And so, consider how you repair it. Consider how you stimulate healing. Maybe consider using an augment. Maybe consider using biologics, depending on your kind of own algorithms. SCR, as I said, this has been a big addition, and there are very key indications to keep in mind, but when your patient fits this, this is going to be a really good option for patients. You know, my, as I kind of move forward doing this more and more, I've been happier and happier with my outcomes with these. Tendon transfer, really a fixed patient population, but kind of know when they're indicated, and know which tendon transfer to do with which patient. And there are patients out there where this is probably going to be their best option. There are some new options emerging, whether they be biologic options, or I showed you the case with the subacromial space balloon spacer. So, there are some things out there, so kind of pay attention to what's coming down the pipe. And then, you know, you're kind of tried and true arthroplasty in the older low-demand patients, or where you really just don't have another option. Reverse is a great option in these patients. So, don't be hesitant to do so, as long as you're indicating it appropriately. So, that's all I have prepared for you. I think probably went pretty late here. Well, actually, we've got about five to ten minutes if there's questions. And again, thanks for having me give this talk. And again, kudos to Mark and Jeff and the crew for putting together a really amazing webinar series. Yeah, thanks for that, Steve. Appreciate that. Thanks for doing it. Great talk, as always. So, we'll take questions now through the chat function on the program. I've got one question here from Jonathan Hughes. For your SCR indications, what about the heavy laborer? They are young and active, but do you have a certain level of activity that is too much and contraindicated? That's a really good question, Jonathan. And honestly, the hard part is this is a really common problem in that patient population. And so, you're going to see these, and it's really hard to solve that problem. So, the honest answer is if I'm spooked at all, I don't think an SCR is something that at this point I'm indicating all that widely. I don't think, you know, so heavy laborer, if they don't have arthritis, I think a tendon transfer might be a good option in that patient. In particular, if they're really disturbed most by function and not pain. But frankly, a lot of them come in primarily concerned about pain. And so, in that patient population, you need to be really thoughtful. A reverse is not great in a laborer. These laborers can do well with rehab, and so I'm certainly going to exhaust the conservative stuff first. If there's no arthritis, if the subscap is intact, if you have a kind of a good feeling about the patient, you know, this is a kind of a motivated patient, then an SCR is an option. But if they really have a high demand job, you've got to be really thoughtful about whether or not they're going to honestly get back to that particular occupation. So, there are, as we all know, some dead ends in the labor population, especially in the work comp population. And in my opinion, I think SCR is a really dicey option in that patient. And so, by the book, the answer is no. Do I occasionally consider it? I do. But you've got to really, really be honest with the patient and really kind of share the decision making on whether you proceed or not. Steve, to ask you a question, I applaud you for doing, you know, some of these cases. These are, some of these are really complex cases. And I've gone away from doing, you know, total shoulders. I gave those up, I don't know, five or six years ago. And reverses and things like that. And I did SCRs for a while, but I felt like if I wasn't doing the reverses, I really shouldn't do the SCRs. Because there's a, there's a use for both of those things in that patient population. And if you don't understand which patients suit which indication best, you only have one hammer for the nail. So, I kind of felt like I was, I needed to give up both of them at the same time. Talk to us a little bit from an educational standpoint about, if you're going to do complex shoulder, you probably need to have a lot of tools in your belt. As you said, it's a tool in the belt with the various things. And it really is a conglomerate of options that you have to understand all of them to really be good at being a complex shoulder surgeon. Yeah, I think that's a really on target question. I think you hit the nail on the head with that particular hammer. You know, the problem is, is if you do the, everything short of arthroplasty, then quite honestly, I think it's tricky to not be kind of coaxed into kind of overextending yourself and not indicating the arthroplasty when really it's the right thing to do. There's a lot of patients where it really is a judgment. And frankly, it comes down to a very honest conversation with the patient. The patient, in the end, bears some responsibility and certainly has kind of the largest role in judging, all right, what are we doing here? You know, if you think the rotator cuff might be reparable, but you're on the fence, the patient would prefer an attempt knowing that there's a chance of failure and, you know, a real chance of failure, then I don't think that that's the wrong thing to do. And same thing with an SCR. Obviously, the issue with SCR is it's a big operation. So it takes, you know, it's not a quick surgery. It's a long recovery. And it's not an inexpensive procedure, right, when you kind of add up the anchors and the cost of the graft and things of that nature. So you got to be really thoughtful about your indications. But in the end, it's a judgment you have to make with your patients. So I think your point is really on target, Jeff. You know, if you're going to take care of these patients, it's probably best if you kind of at least understand the algorithm and know when the right thing, you know, what the right thing is to do. And if you're not, somebody does arthroplasty, you can still take care of these patients. But you got to be really honest from the standpoint of, all right, this is probably better served with an arthroplasty. The other thing I'll tell you, and we talk about this all the time, and, you know, I've done ICLs at AOSSM and things of that nature. You know, doing arthroplasty in the sports world is very, very facile. Our fellows get exposed to a lot of it, obviously. I think most fellowships have an element of it. But I would encourage all of you guys, the fellows who are on this call, to incorporate this into your practice. You know, it requires, obviously, some technical expertise. But it's a really rewarding patient population to take care of. And it expands what you can kind of contribute. So, you know, if you can, you know, if you're somebody like Jeff, where, you know, you have obviously a very targeted population and, you know, a younger patient population. And, you know, you're busy with doing the other stuff with the elbows, et cetera. You know, maybe that's the way you go. But if you have a shoulder-based practice, I would certainly encourage you to do arthroplasty. Absolutely. I agree. Got another question for Al from Alex Brown. For the massive cuffs that you repair, are you tying down the medial row, then placing those same suture limbs through the medial aspect of the graft? Or tying after passing those medial row suture limbs through the graft? So that's actually a really sophisticated question. So kudos to Alex for actually thinking about that. Because I showed the video. But I think that's important, right? Because you're trying to do two things. You're trying to repair the patient's tendon to the tuberosity. And then you're trying to augment it with the graft. So the honest answer is both. So what I normally do, or what I try to do, is I'll have double and triple-loaded anchors. And I'll have kind of this hybrid of double and, you know, kind of single row. Or kind of basically mattress and simple. Or, you know, some mattresses I'll tie as, you know, kind of a non-graft stitch. But basically, with each anchor, I'll have one suture that's for the graft. And it goes through the patient's tendon. But it's tied down at the time that we place the graft. And then the rest of the sutures are for the repair itself. So what I'll do is I'll pass all the sutures. I'll sequentially tie. And I'll do the rotator cuff repair component first. But I'll save two or three or at most four mattresses that are the most medially placed. And I'll bring those over and out. And I'll use those to incorporate the graft. So that allows the graft to kind of overlap your repair. And actually kind of sit down a little bit medial to the repaired tendon down to tuberosity. And it allows you to kind of accomplish both a repair as well as an augmentation. And then you saw with that video, then the final steps are to kind of tension the lateral aspect of the graft. So you have multiple kind of, you know, steps to allow both the repair itself to be done and tensioned, and then the graft itself to be done and tensioned. Hey, Steve. That was a great talk, great overview. There's a question here that came to me directly from Ian Murray, who's going to be one of our fellows next year. He wanted to know what your thoughts are on why you thought PRP in the shoulder is so much more disappointing than other tendon applications. Yeah. So he's, I mean, the data is what the data is. So it's not that it's my own opinion. That said, you know, as far as why that might be, I think there's a lot of, you know, different considerations. You know, the hard part with PRP is it's kind of like a, it's kind of an umbrella term, right? So you've got to understand the different elements of what's in the particular product you're using. And so I think the challenges with PRP are, number one, I don't think you're comparing apples to apples, so each study has got its own elements. I think, number two, you may be asking a little bit too much of these growth factors, because again, you have a kind of an impaired blood supply. And so the cellular contribution of PRP is probably not there. Rodeo's study in particular used kind of a more solid or viscous type of PRP. And talking with him, I think he thought that it might have actually impaired the ability for, you know, kind of the tendon to kind of cement down and actually try to hit the heel down to the tuberosity. So, you know, the actual, you know, the kind of the makeup of the PRP may have some relevance, too. And then the final issue, quite honestly, with any of these biologics to augment a rotator cuff repair is getting it to actually stay in place long enough to actually do something. And so you saw with that one case that I showed where I was using BMAC, basically what I do is I put that needle there, and then I drain the joint, you know, the subacromial space, and then I inject the BMAC as the final step. So hopefully it kind of stays in place. It kind of wicks to the graft. I'll soak it in, soak the graft in it as well. The idea being to try to keep some of those biologic elements around long enough to do something. But the reality is, is that may not happen that well. So, you know, I think some of the limitations from a biologic standpoint is actually just getting it to stay there long enough to actually enact a repair. So those are my thoughts on why it maybe didn't, hasn't worked as well. But the honest answer is we just don't know. But I probably, you know, based on the data that's out there, I think cell-based, so, you know, whether it's, you know, MSC is taken from, you know, whether it's bone marrow or elsewhere is probably where we're going in the future, more than likely. But there may be other stuff out there biologically that may kind of surprise us as far as its contribution to help repairs heal. Let me ask you another question about SCR. I don't follow this literature nearly as closely because I'm not doing as much of the complex reconstructive shoulder stuff anymore. As Mike Friel will attest to, you know, I consider the hip is more of a challenge than something straightforward like an irreparable cuff or something like that. But the SCR data, I thought the SCR data was trending towards not being able to match Teru's, you know, Mihata's work and that there were a lot more early failures with the SCR and people talk about different types of techniques and number of anchors and that sort of thing. So, but what you presented seemed like it was mostly pretty positive, even though it's not equivalent to Teru's data, it is, it's actually pretty good. Do you want to, can you expand on that a little bit? Yeah, I mean, I think, and I was trying to be kind of politically correct as far as I presented, you know, those outcomes. You know, if you're asking my opinion on it, I don't know that we have great evidence yet, quite honestly, Mark. And it looks like Friel just chimed in. Maybe you can unmute and back us up here a little bit. But my impression of the data, so when I look at Mihata's data, I mean, obviously, he is to be given a ton of credit for, you know, essentially inventing an operation, by and large. And, you know, introducing it and it is a tool in the toolbox and, you know, my own personal experience with patients, it can be a really, it can dig you out of a deep hole. I do think when you look at the evidence that is out there, you know, Mihata's data, both the short-term, the initial study, the two-year and the five-year data, you know, the outcomes are superb, I mean, they're very, very good to the point where, you know, when you compare them to other studies looking at this challenging entity, which is, you know, these big cup tears or irreparable cup tears, it's really hard to get 90-plus percent success rates and certainly hard to get, you know, 80 to 90-plus percent healing rates. So it's really, it's hard, it's a different operation. He's using autogenous tissue, it's doubled and tripled, so you've got a really, really fat graft. I mean, it's a really, really more robust thing. And we're taking an allograft, you know, that's been basically kind of sitting on ice. It's maybe three to four millimeters at most. So even though it's a kind of a thick piece of allograft, it's really not anywhere near what Mihata's putting in. And so it's a different operation. And if you look at the outcomes, they're not bad, but they're not great, you know. And I think the problem is, is there's a lot of small series and maybe some bias and short outcomes and, you know, a bit of a mixed bag as far as patient population. So I don't know that there's anything great out there. I do think that a well-done level one study looking at SCR, you know, is lacking at this point. I suspect it's coming, quite honestly. And there's some registry data, quite honestly, that's probably out there that we could use, too, to get a bigger kind of, you know, kind of look at it. But yeah, I don't think the data's the same, Mark. I think when you look at the U.S. data, you look at the, you know, the data from Asia, it's not the same, and that's maybe because it's not the same operation. And it may be just because we're not as skilled at it. You know, you're looking at pooled data versus one surgeon who does a lot of these operations. Hey, Jeff, you want to mute Freehill? I'm sure he's bursting at the brim. Can you hear me? Oh, yeah. Hey, that was awesome, Steve. I've been fiddling with my camera here, and it's not going. But yeah, with the SCR, I, when you were presenting, I'm the exact same as you. I was kind of excited about it, and then was really excited with some of the results, and then that went the other direction with a couple others. And then it just became more narrow and narrow indications. And then I looked into the literature a lot like you and figuring out how Terry was getting such incredible results, and I think that when we look at that thermal allograft, it's a bit thicker, but once it starts to get wet, it gets pretty thin pretty quick. And I started cutting them down and stacking them. It takes time. It adds more suture. It's a little bit painful, because I'm not so sure. It's not just a spacer effect, but it does work in the right patients. Yeah, I mean, if you try to make a bigger graft and do it arthroscopically, it does add a huge layer of complexity. You know, I agree. I do think it's, it'll be interesting to see how this operation evolves. And it's already evolved. You know, to put this talk together, I actually went back through and reviewed some of the stuff that's out there that, you know, that's pretty new. And from the standpoint of the technique, it's evolved a good bit. There's some other stuff out there as far as, you know, if you double the graft. You know, people are using, you know, graft on the acromion. I think you guys may have seen that acromial, like, pillow operation. So people are trying other options to try to kind of capitalize on what Mike was just saying where, you know, if we don't think it's a humeral head depressor, you know, like really retensioning it, and it's more of a spacer or kind of a bumper, maybe you do a different approach. And that's where I personally have some excitement for this subacromial space balloon. I'm curious to see how that works in the right patient. And frankly speaking, it looks like an easier operation. And this, if we really are just getting a bumper effect, maybe that's going to be something that will have a kind of a large role once it's out on the market. But, you know, the data certainly is still out on that. So, but it's an interesting area. We see these patients all the time. And it's just kind of what do you do with them, and how do you kind of make them better? And so it's important to kind of have tools in the toolbox, try to work through an algorithm, be thoughtful, but individualize each patient approach. And in the end, try to do the right thing. And, you know, sometimes you win, and sometimes you lose. But be comfortable with your decision making. Chef, you're muted. Chef. With that, we're going to say thank you to the fellows who were on the call. Thanks for all the faculty. Thank you, Steve. Great talk. Please tell your family I said hello. And I look forward to seeing all you guys soon. Everybody stay safe. And we'll be back on tomorrow night. Thanks, everybody. Thanks, guys. See you. Bye-bye.

irreparable rotator cuffs

management strategies

tissue compromise

grafting procedures

tendon transfers

superior capsular reconstruction

patient selection

thick graft

positive outcome

surgical options