These are not really pearls, more like categories, things to think about as you do your cases. Basically I think all of us have had the fellow that looks at the MRI even before walking into the room, and they say, hey, nice tear, I want to see what your double row repair looks like. I think we want to know a little bit more information about that patient before we take them to the operating room. We want to know the patient's age, the acute tear, chronic tear, what activities they're interested in, the physical exam. I think it's important, obviously, to look at the cuff, but don't ignore the biceps and the AC joint because you won't be able to look at those intraoperatively and try to figure out whether that's really a pain generator or not. Looking at the x-rays, a lot of times we kind of blow by those, but you want to make sure that you don't ignore if the person's got significant arthritis or osteoporosis and then modify our fixation techniques. And obviously the MRI is important to look at the cuff, but also just as you guys have talked about, muscle atrophy and fatty lung filtration is going to play a big role in your decision-making. Intraoperatively, we start with the intraarticular part of the procedure. I think everybody in the room probably is quite comfortable with all that. We usually do the capsule release along with the cuff repair. That seems to be helpful in terms of pain management and being able to get the patient's range of motion back more easily. Subacromial space, as I think Dr. Gettleman spoke about, really key to do your bursectomy well. A lot of times we get going, start to do the cuff repair, next thing you know the visualization is compromised and every step takes a lot longer. So make sure the bursectomy is adequate. Try to figure out the pattern, the degree of tearing, quality of the tissue and so on. And then in terms of the cuff repair itself, you want to pick the right tool for the job. We've got double row, single row, the anchor type. A lot of times people go in with the idea, well, I'm just going to do a single row or whatever. You want to individualize the treatment based on the pathology that's there. And then obviously the rehab is critical. You want to communicate with your therapist to make sure that the patients are on the right protocol and heading in the right direction. Thank you. »» Just a quick question. Go ahead, Frank. You can come on up. The yawn and then the rest of the panel. Anything on preoperative imaging that are going to give you clues of when in a revision situation you're going to need to use say bone graft or trans-osteous tunnels or do you just find that out game time? Jan, we'll start with you and run down the panel. »» You mean in terms of osteoporotic bone and... »» Yeah. Is there anything like you just wait until it happens? I mean, we get the fact the small anchor doesn't work and then you put the bigger anchor. But when the bigger anchor doesn't work, now you've got a bigger hole. Is there any way to prevent that? »» No, I think the patient's age and sex helps you. If it's an 80-year-old little old lady, I think the game is going to be different than for a 55-year-old male. The x-rays can show osteoporosis if I've got significant level of concern. DEXA scan is going to give you additional information. »» John? »» Just to be brief, you can look at obviously tendon thickness, tendon quality, muscle quality. But one way is not everything can be a double row. Just bring the tendon to where it can go after you do your releases and you can try to prevent having anchor pullout if you can't do a double row and do a single row more immediately. »» Mark? »» Yeah. Your best bone is just underneath the articular margin of the humeral head. And so if you really maintain that tent peg angle or dead man's angle and you stay right underneath the subchondral bone, even in an 80-year-old, you should be able to find good bone. And that's why I tend to do single row almost exclusively. »» Craig? »» In my population, the military, I have to make sure I have really sharp drill bits because otherwise I'll break them off. So bone quality is not a problem. »» Just the elderly, post-menopausal, female, agella novus, I've always prepared, especially over 75. »» Pat, anything to add? »» Yeah. And Mark's absolutely right that that's where the best bone is, right in that early subchondral bone. And then you have a big gap where it's often soft bone. So if you're committed, you can't get anything up top either. You just have to go as far down in the humerus as you can get to get a second row. And you can get down pretty far and usually to get cortical bone. But that's a problem. »» All right. Frank, take it away, bud. »» Okay. The only thing I'd add to that is don't forget just a pure trans-osseous approach. If the bone is that weak, you can bypass the bone to some degree and use an old technique that many on the panel have been trained on. And there are devices out there. There's an Israeli device. There are some other devices as well. They're available. So regarding the coracoid transfer, these are the five things that I'll discuss. We heard a bit about setup. I think it is important to make sure you try and get the scapula in the coronal plane. So get it out of the scapular plane so that you'll have more of a direct shot with your screws. So whether you use towels along the medial border of the scapula to try and get it back in that position. Some authors have suggested using a roll towel between the scapula or an IV bag that's wrapped up. But I tend to just focus on the medial border. Arm positioners can be useful. You can use a padded Mayo stand as well. You just want to really protect the arm and be cognizant of malposition of the humerus for extended periods of time, again, because of neurovascular compromise. I always start with an arthroscopic approach for revisions. And the real issue there is to just be able to remove sutures, remove anchors as necessary. And I almost always use it in the primary setting as well. I think the scope is very useful to look at the posterior capsule labral area, the biceps labral complex, and also to prepare the glenoid so you can do some of your prep work before you actually move to an arthrotomy. And I do not perform an arthroscopic latergy, just to be clear. On the osteotomy side, it's all about exposure. And once again, I would emphasize the use of the retractors, the row and the Hohmann retractors above. That'll really give you adequate exposure. And adequate length. These illustrations are courtesy of Preventure, Tokish, and co-authors, which is in the chapter in an upcoming Rockwood and Madsen sixth edition. So strive for two and a half centimeters, but at minimum two centimeters. Avoid compromising the CC ligaments. Osteotomize medial to lateral. You want to protect the neurovascular structures, which you can see on the photograph as well as in the talk this morning are so close. And then once harvested, take care to avoid musculocutaneous nerve injury by excessive traction. Where do we put the split? Use the two-thirds, one-third. I think that's very appropriate. Use a deep galpy or a 90-degree galpy for exposure before you get to the capsule. And then really focus on the medial exposure. You're really not trying to get out to the intertubercular sulcus or the biceps tendon. Make a vertical split in the capsule. Use your retractors appropriately, a facuda laterally, and a row medially. And fixation is important. Obtain posterior glenoid purchase. That is very important, bicortical purchase. You can use a button technique as well. Thanks again. Frank and the panel, when you were going over what to do when your graft cracks, do you consent your patients for, say, distal clavicle graft? How do you consent them for the disaster? I usually have an overarching consent and basically discuss all the options and ask for their permission to do what I need to do to make it right and provide them with the best outcome. Go ahead, Pat. I have a question for Frank. Because you mentioned using alcohol before in your presentation. Have you done that? And did you consent for that? I have not. It's just an option. It's an option. You can do it yourself with nothing left. That's an option. Any other tricks from the panel that have cracked their bladder jay graft? Okay, good, crickets.

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