So thanks, Steve, for your part. So as far as massive tears, what we're going to really focus on, that's really where massive tears or large tears where you're going to use a graft or a patch. And so as has been nicely pointed out here, we certainly see high re-tear rates in the large and massive tears. And there's been a recent systematic review of primary repairs of massive tears. And whether you do a complete repair or partial repair, if we look at the more modern techniques of repair, which I think is important, you still see rather high re-tear rates. If you can do a complete repair back to the footprint or just a partial, you're still seeing those higher failure rates. And if we're not able to accomplish a cuff repair, then we're going to certainly expect to see rotator cuff arthropathy and further degeneration. And so what I usually want to talk about in these talks is what do we really do? We're not talking about the 60 or especially 70-year-old patient with a massive tear, perhaps, where sometimes it may be better to think about a reverse. We're talking about sometimes these younger patients where you're not seeing arthritis. And everybody has seen these type of patients where you're really wondering what to do. And here's the first patient of mine where I ended up getting interested in grafts. It was a 41-year-old hockey player. He got checked into the boards and exploded his cuff. And you can see some of these pictures, but you'll note on the sagittal view here that he really doesn't have fat infiltration. It's rather acute injury. But you look at this, if you do an arthroscopy, and you really see that cartilage, and you think, is this somebody I really want to do a reverse? I'm probably not. And you're going to be thinking about your options. You certainly want to avoid some of these problems here. So I'm really going to talk more. I'm not going to talk so much about primary repairs or really an augment for a partial thickness. I'm going to really stick a little bit more the grafts for more for bridging and SCR. And I'm not going to be talking about tendon transfers or get into that side of things. I'll talk a little bit about SCR. One of the problems with grafts or patches is that this is a relatively new concept. And even though I agree with Steve that patches were used a little bit in the past, if we really look at how much were they used in the past, they certainly weren't published about for a long time. And in fact, like 70% of the literature has been published on this since 2012. So pretty recent literature. And 100 articles on grafts or patches since 2018. So we've really learned a lot about this. But it's still one of the problems when you're looking for evidence is that we're still learning here. And I think it's because we're trying to get better and offer something to the patients that have these larger massive tears, especially when they're younger. And there was a nice article in the arthroscopy journal about how grafts are getting a bad rap. And we heard just a little bit of the talk previous to mine about the bad rap on grafts. But surprisingly, good results are seen in many of the studies. And even though it's not level one evidence, again, it's like trying to understand and learn, which we frequently do in sports medicine and arthroscopy, is this is how we get better as we begin trying to learn. So as we start seeing enough data to at least put together systematic reviews to begin examining this, we think about at the bottom here with the asterisk, if you think about of our primary repair, retear incidence is in the 35%, 40% range with modern techniques of repair. When we start adding a graft, we see those retear rates fall. And even getting to the studies that discuss interposition, the retear rate is quite a bit lower than you're seeing with a primary repair. Now, the problem with anything when we start talking about xenografts is when you review that literature, what you really need to do is realize that all the xenograft studies include the restore patch that got taken off the market because it wasn't a good graft. And so when you take out, as I have done, when you take out the data from restore, actually the xenografts look a lot better. And so I would just say they probably shouldn't be completely discounted yet, but something to watch for. And when you read the literature, just remember the xenografts still all the literature is including those restore patches that weren't successful. So another systematic review in 2017, historic rates of retear high in that 30 to 40%. You're seeing augmentation or bridging with grafts. You see the retear rates in studies dropping to like rates are 20 and even 10, like 7%. And now I'm looking at some also systematic reviews, but including some comparative studies, like head to head using in this study, the first one here looking at in Lewington's review, looking at biceps bridging, adding that to the cuff repair versus partial repair alone. You see like almost like half the retear incidents and then using fascia lata. This isn't an SCR, but using fascia lata as to augment a repair versus partial repair alone. You see how much more they're more, certainly more intact in the fascia lata augmented group. And then once again, observational groups seeing like more success when you're using a graft. Here's a third comparative study. And this is looking at massive tears, partial repair versus that repair using a dermal allograft to augment. And you see the constant scores in Oxford scores better with the group that had the allografts. Remember these are head to head by the same group. And here's a fourth comparative study head to head. And this is Mahada's group. And this is very interesting because it's arthroscopic cuff repair, like in his group or him doing this versus arthroscopic cuff and adding an SCR over the cuff repair. So this is not SCR entirely, just bridging here or something. This is with the cuff repaired also. And you see that amazingly, he had quite a low incidence of retear in his groups, only like 4% retear and 8% with cuff repair, but that 8% had the type three cuff integrity, which if you look there is insufficient thickness without discontinuity. And then when you looked at adding the SCR to an arthroscopic cuff, then you're seeing no retears and no cases of that type three integrity. So interesting head to head study there. As you just heard in Dr. Weber's talk, we don't know the impact of graft thickness on these results. And that's something I would just say, it probably makes sense to people that a thicker graft may have more of an interposition effect like that cushion as you heard about, but I don't think we know yet the role there, but I think it's something to pay attention to. We see that thinner grafts like the one millimeter, some of the dermal grafts are quite thin and we're seeing more failure in some of the early literature on those more thin grafts. And we saw this again in the systematic review that the acromiohumeral distance, as you would guess, appears better post-operatively when there's a thicker graft. And so I think as we think about this and look at this over time, pay attention to graft thickness. And so on the pseudoparalysis side, you just saw a paper in Dr. Weber's talk where using graft augmentation did not reverse pseudoparalysis. Mahada's group, which granted is thicker fasciolata for SCR, but they were able to reverse pseudoparalysis and certainly in a very high percentage of their patients. And those that, if the graft did not stay intact, those are the only patients that maintain pseudoparalysis. I think most of us would think it's a little bit hard to duplicate his results, but it's certainly something interesting and for us to pay attention to for our patients. And then looking at Mahada's, if we say SCR long-term, really, he has the best evidence overall for SCR, for sure, looking longer term. And now that he's having results even out to 10 years, but certainly over five years, the patients are doing quite well, returning to physical work and returning to sports. And so I think it's something that he's certainly an author that I think we all pay attention to, but what we really wanna know is how our patients are functioning. Hopefully their grafts are staying intact. We know if the grafts or the cuff stays intact or graft stays intact, the patients are gonna do better. And so in summary, there's certainly, you heard evidence from Dr. Weber and then you've seen some evidence from me. I'm someone who's done over 600 grafts over the years before it became more popular. I've learned a tremendous amount myself about using grafts mainly for interposition, but using SCR in my practice, more when patients have fatty infiltration, more atrophy when they're getting a grade three or higher, then I think it's a little bit more reasonable in my practice to do an SCR. This is a patient, if you look at the photo or the images on the right, 45 year old patient, really patient has very little to no arthritis, only 45 years old, failed a cuff repair, only three months out elsewhere, came in to see me and I saw her at four months and she'd had a fall and was quite nervous and was interested in MRI, which I was interested in too, because I like to see how she was doing. But I think it's really gonna make a difference in a 45 year old with very little arthritis. And I think this is still something that's important to know in the armamentarium. I couldn't agree more with Scott Rodeo that we have a lot to learn about the biology and augmenting, but I think it is something to think about in your patients to get off the bench and use a graft, especially for massive or large tears. Thank you.

grafts

massive tears

rotator cuffs

re-tear rates

patient outcomes