I'd like to have the next set of presenters come up to the stage, please, if possible. And thank everyone in the audience for hanging in there, we're nearing the end. So we're going to start with a really good session on complex shoulder topics taken from the instability to the cuff now. So our first presenter is Michael O'Brien, he's going to talk to us about augmentation and rotator cuff repair, when do I pull the trigger? Thanks Fani, and I want to thank the program chairs for the invitation to be here with you today. These are my disclosures. So my current algorithm on when to augment cuff repairs is when I want to add biology, which is usually going to be in the setting of a revision cuff repair with good tendon tissue, or in a primary repair in a patient with advancing age or medical comorbidities, or when I want to add strength in the setting of multiple previous surgeries with a thin atrophic tendon and type 2 failures. We know that poor prognostic indicators for cuff failure is advancing age, medical comorbidities, massive tears, and revision surgery. So these are all things we can do to augment the biology, and in this talk we're going to focus specifically on a biologic collagen implant and dermal allograft. So here's a prospective case, this is a 66-year-old diabetic male with a massive cuff tear, and when you look at the MRI you can see that he's got a full thickness tear of supraspinatus and infraspinatus, but good tendon quality, nice thick tendon, and very little atrophy. So this is a good case for an augmentation. So this is a right shoulder in the beach chair position, you can see the tendon's reducible, so we'll perform releases, debride the tuberosity, place our anchors, do a microfracture for marrow stimulation, you can reduce the tendon with a grasper, pass our sutures in mattress fashion, we'll tie the medial row, and then when there's adequate tissue we'll bring it out to a lateral row repair, so there's a double row repair. Now we're going to augment this with a bioinductive collagen implant to improve the biology. So the implant's brought in from the lateral portal, it's placed over the cuff repair right at the bone tendon interface, and then it's secured with PLLA staples medially and peak bone staples laterally. And so that completes the augmentation with a bioinductive collagen implant to increase the tendon thickness and improve blood supply to assist with healing. Another case is a revision tear, so this is a 53-year-old female with a recurrent cuff tear who fell three months post-op, and again you can see on the MRI nice quality tissue with a thick tendon and very minimal atrophy, so also amenable to repair. So this is a right shoulder again, so here in the subacromial space you can see re-tear, good thickness on the tendon, the sutures are removed, the tuberosity's debrided. When we view from lateral you can see nice thick tendon that's easily reducible. So we'll microfracture the tuberosity, place our anchors, reduce the tendon with a grasper, pass our sutures in mattress fashion, and again when there's adequate tissue length a double row repair can be added with lateral sutures, and then we'll add in the collagen implant to assist with biology in the revision setting. Looking at the outcome studies, this was first looked at by Des Bacher in 2015, so he looked at nine patients with medium full thickness tears, and in all of them he found two millimeters of new tendon-like tissue with no re-tears and 90% satisfactory results. We looked at our series at Tulane of 23 large and massive tears, including revisions, and we had a 96% healing rate with a 91% success rate, and no difference in healing or outcome scores between large and massive tears and primary and revisions. Bushnell looked at a multicenter study of 115 medium and large tears with a 16.5 re-tear rate at one year and significant improvements in all outcomes, and Lou McIntyre looked at a multicenter registry of 192 cuff repairs, mostly medium and large tears with a 5.7 re-tear rate at one year, and statistical improvement in all outcome scores. So then we'll use a dermal allograft when we want to add strength to the repair. So this is a 75-year-old male with a recurrent cuff tear. He's one year post-op from surgery, and he's got a type two failure. So you can see in the MRI on the bottom that he's got a stump of tissue on the tuberosity with a tear at the muscle-tendon junction with minimal atrophy. So at surgery he's got a medium-sized tear at the muscle-tendon junction with a good cuff of tissue still attached to the tuberosity. So this one will do a side-to-side repair with three margin convergent sutures to pull the tendon together. So that completes the repair there. Then we're going to bring in a dermal allograft. So that's measured on the back table. Sutures are marked. It's pulled in with a double-pulley technique. So you can put a double-pulley in the medial tendon to pull the tendon in, lay it down with a probe, and then secure it with simple sutures, anterior, posterior, and medial, and suture anchors laterally. Another case, 58-year-old police officer with a recurrent left rotator cuff tear who's had three previous repairs. His MRI shows he's got good length on his tendon, but a very thin atrophic tendon. And he has grade two atrophy of the supraspinatus and grade three atrophy of the infraspinatus. So at his surgery he had good tendon length, but an atrophic tendon. So a double-row repair was performed and dermal allograft augmentation. When we look at these outcome scores, outcome studies, sorry, Barber and Litchfield looked at 42 patients with two-tendon tears. They were randomized to a single-row repair with and without augment. The intact MRI showed intact repair in 85% in the augment group and 40% without. Peter Millett looked at 13 patients with two-year follow-up with one re-tear, improvements in ASES scores. This also 23 revision rotator cuff repairs by Joe Burns with a 31% re-tear rate, but improvements in outcome scores. And the Rothman group looked at 35 repairs, mostly revisions, and they had a slightly higher re-tear rate at 48%, but maintained improvements in outcome scores. And they saw that there was a higher degree of re-tear when there was preoperative fatty infiltration of the infraspinatus, sorry. Finally, systematic review showed that allograft augmentation is superior and better than xenograft augmentation. So when to augment, when I want to add biology, I'll add a bioinductive collagen implant. And when I want to add strength, I'll add a dermal allograft. Thank you. So our next speaker is Dr. Cole is going to educate us all on biology. Got it. Okay. So I think one of the most interesting aspects of rotator cuff disease is that it's probably largely attritional, and then trauma brings it to our attention. But this is a disease of time and degeneration, and that's why we see increasing prevalence as patients age. But lots and lots of people run around with rotator cuff tears and have no symptoms. And it's those who get out of balance that we tend to see in our office, and ultimately may be requiring fixation. What do they want? Our patients want less pain and more function. And I think the research that we've shown is that when you compare pre- to post-operative outcomes, they will actually take a little bit of pain as long as they get some of their function back. And we often say, well, look. And I think what was just discussed, they said, well, their outcomes are still good with a 43% re-tear rate. When you look at outcome scores that embody strength as one of the primary measures, patient satisfaction is actually generally less than those who have an intact cuff, given the fact that they can maintain strength. And we have all of these biologic challenges, and it becomes a little bit difficult to understand why we re-tear or failure to heal, and which one is the most important. This is a really interesting study that I think is worth holding on to. It's a lot like the ISIS instability score, and this is the Rohy Healing Index, and it takes into consideration age, tear size, retraction, and bone marrow density, and so forth. So it's single surgeon, over 600 patients, 12-month follow-up by MRI. And what was pretty stunning is that when you add it all up, when the Rohy score was greater than six, the healing rates, the percent healed, went from 67% to 37%. So it really drives home the point that biology matters in terms of keeping the tenant intact. Ideally, we'd love to have emphasis regeneration, but really what we often get is scar and continuity. And that's why we're talking about this concept of improving biology. So we can use scaffolds to improve material properties, or we can use biologics to improve structural properties. You just heard an excellent talk about the role of extracellular augmentation. I would just say if you turn to the literature and look at preclinical, in vivo, and clinical data, I think there's a good argument to be made clinically that this is a useful adjunct, and sometimes even the setting of primary repair, depending on, for example, the Rohy Index. This will be published next month, so you don't have to go through this complexity in arthroscopy, but we basically looked at the economic aspects of cuff augmentation, because that's a very big part of the consideration, given the fact that these are performed in the outpatient setting. And one of the things that we identified is that you can sort of buy yourself an additional quality of life here by using rotator cuff augmentation when you take into consideration re-teriorate to the cost of revision and so forth. So that's something you'll find out, hopefully, next month. So what about augmentation? This has been, you saw the technique where you sort of parachuted in. It's been technically a difficult operation, time-consuming. So I think there's been some advances, technically, to use dermal allograft, which make this a much easier operation. But basically, these graphs have been shown to be permanently present. If you look from canine literature up through MRI, as you see here, if you just follow that middle picture, we follow our patients now prospectively, and each of these is showing good integration, much like Jimmy Cook's animal study showed with dermal integration for partial thickness tears. So what about biologics? The two main biologics that we deal with are PRP and bone marrow aspirate. When it comes to PRP, some of the in vitro work that we've experienced is that leukocyte-poor PRP actually promoted collagen synthesis in diseased rotator cuff tendons in a culture, as well as decreased catabolic cytokines. And that was compared to leukocyte-rich. So that was some of the early in vitro work that we did. If you look at the role of PRP in other aspects, it actually can recruit MSCs into the area. So that's why it might be helpful, for example, in a model of, say, cartilage repair. And why it might be helpful in a setting of rotator cuff healing. The literature is becoming a little bit more clear, I think. We've always said, well, the jury's not out, need more studies, and so forth. But there's been 17 randomized controlled trials. And it has been associated with a reduction of re-tear rates, especially for small to medium-sized tears. And maybe it's the numerator-denominator function, but there is a tendency to see more clinical trials utilizing leukocyte-poor PRP compared to leukocyte-rich. So what about MSCs, otherwise known as medicinal signaling cells? I would urge you to stay away from the terminology of stem cells when talking to your patients. Think of these more as sort of growth factor warehouses or little pharmacies that can produce all of these effects, including angiogenesis and anti-scarring. And may upregulate and modulate the environment in terms of reducing inflammation and may be immunomodulatory. There's been a couple of studies that have been interesting, and I think I would look at the one on the left. And this is the one that's frequently quoted by Hernegau that looked at 45 patients in each group with and without bone marrow concentrate and showed a pretty stunning difference at 10 years. 87% healing when bone marrow concentrate was added versus 44%. Most of that was by ultrasound and some MRI. There has been some interest in fat and adipose tissue as well as taking fat, digesting it with trypsin, which is a whole different drug pathway. But fat has actually shown to be potentially associated with reduced re-tear rates at one year follow-up. This is a study that is hopefully going to be done soon, where we had 91 patients who underwent transoxic equivalent repair of a supraspinatus tendon. We augmented with bone marrow aspirate. And just some provisional results I'll share with you. 91 patients, half and half in each group. We saw about a 25% improvement in SIGGAYA score at one year. And it was a significant and strong association between bone marrow concentrate and lower SIGGAYA scores at that time point. There are some other options to be thinking about. There's some emerging work from Gus Mazzocca's lab in terms of how we can actually capture Bursa and potentially put it back in place. We have lots of things that we sort of throw away when we do surgery. And there's the potential for a cost-effective way to use autogenous tissue to upregulate the environment. And then finally, there's a number of technologies that are available that are looking to actually do what we'd love to do from time zero, which is recreate the emphasis. So there's DBM. There's amniotic tissue. There's a number of things that have been evaluated to potentially restore the insertion site to that fibrocartilage transition zone. So rotator cuff tears are associated with poor biology and are largely attritional in nature. And they heal with scar and continuity with very poor material properties. So we look to improve both material and structural properties. I think there's some pretty good data supporting extracellular matrix. And now we'll start to look at the econometrics to see if it actually makes sense. Growth factors are probably not going to be enough. We're going to need other things like scaffold and cells if we're really going to do the job we're looking to do. And I would conclude with that there is some evidence that's accumulating that is in favor of PRP and bone marrow aspirate. Thank you very much. Thank you, Dr. Cole. And as always, Grant is on the cutting edge of teaching us a new technique. Thanks, Fonny. So I'm Grant Geraguse. I'm Brian's partner here in Chicago. So welcome to sunny Chicago. We're excited everybody could be here in person. So we're going to talk about lower trap transfer. Is this the new standard? So the agenda, what is a lower trap transfer? What does it work? And how do you choose amongst the other options that we've heard some about? And we will hear some more going forward. So irreparable cuff tears, as we've heard, they're a big problem. There are many clinical predictors, as we just saw. One key thing is even if you can repair it, it may not be healable. And so what are our treatment options? There are numerous. Debridement, tuberoplasty, with or without a balloon, tendon transfers. Now those were all the rage some time ago, but kind of fell out of favor and now seem to be coming back a bit. Certainly some challenging techniques, but we'll show you one here. Repair with allograft bridge or augmentation. Again, there's some good results in that, especially if the muscle quality is good. Versatile shoulder arthroplasty may work in the right patients, but some of these young and or active patients aren't good candidates. And then superior capsule reconstruction can work in the right patient, but about 70, 75% success rate. So what is the LTT, lower trap transfer? Essentially you're going to take that lower trap, you're going to think back to your hand surgery rotation first and your principles of tendon transfer. So this really fits them a lot better than our previous workhorse, which was the latissimus. For example, it's an in-phase muscle that fires agonistically with the posterior superior rotator cuff. It has fairly good excursion, and it's a muscle where there's other redundant muscles around the scapula, so it serves as a donor site with minimal morbidity. The one thing it doesn't have is excursion to reach the target, and so that's where the Achilles tendon allograft comes in. Essentially that's just used to make that lower trapped tendon longer to reach all the way to the humerus. So Basim Al-Hassan and the group at Mayo Clinic get a lot of credit for this, as they really came up with a lot of the techniques. Essentially you're going to take that lower trap, it's quite easy to find right there in the medial aspect of the inferior portion of the scapular spine, excise that, and then basically tunnel onto the deltoid to put that posteriorly. So what are the indications? So it's a rare indication, but really the ideal is isolated infraspinatus atrophy. So every now and then you'll see a patient with a musculotendinous junction rupture or intramuscular rupture of the infraspinatus. Those patients do fantastic with this, you can actually get strength back. Other indications that are irreparable mass of posterior superior cuff tears, so patients where you might consider a superior capsule reconstruction, so a lot of debate about when to use one or when to use the other. For me, I really look at the chief complaint, and if the patient really wants that strength and external rotation, that's when I would consider this. Contraindications, advanced arthritis, subscap deficiency, obviously deltoid deficiency, active infection, et cetera. So some good biomechanical data on this showing that it seems to work better than the latissimus dorsi. You can see here, Reza Omid has shown, catabaric study, again, showing that you're going to have better restored balance of the cuff using the lower trap. What is the technique? Originally, it was either vertical or medial lateral incision, there's some debate on that, but essentially you're going to make that little incision there, harvest that, tie an Achilles to that, and the rest of it is all fairly straightforward arthroscopic procedure. So this is kind of what that posterior approach would look like. This is a right shoulder. You can see here, I've got my candle in there to shuttle in under the deltoid, I make that a little bit longer with my Achilles graft, then we're going to go into the joint here, you tie that in place, and that's it. So does it work? The answer is yes. So Basim Alassane has published on this. This was initially an open technique for him, 32 out of 33 had significant improvement in pain and range of motion. Philippe Valenti from Paris published on this, again, excellent results. Look at the improvement in range of motion, ER went from zero to 20, external rotation from minus 10 to 40, so significant improvements, especially in external rotation. Alassane and others, we now use an arthroscopic assisted approach, and again, some of these even had pseudoparalysis for personal. So again, in summary, provides durable and reliable restoration of motion, relief of pain. How do I choose? This is a slide courtesy of Sharif Bashai. So if I've got somebody with thin or poor tissue, I'm going to think about allograft augmentation with just a standard rotator cuff here, if I can get that all the way over the footprint. If I can't get the cuff over the footprint, I think of an SCR, however, if they really have external rotation lags or they really want that external rotation strength, that's when I'm going to think about my lower trap with Achilles allograft. So in the interest of time, I'll stop here. Thank you very much for your attention, and again, safe trip home, everyone. All right, so unfortunately, JT's unable to be here with him, and I am no JT Tokish, but I am going to pinch in here and run through his talk for you here. So his disclosures are available here on the website, and we're going to talk about SCR. So the massive irreparable cuff remains very controversial. We certainly understand that there's a lack of consensus on how to approach this condition, and from what you've heard thus far, there's a lot to learn in terms of how we're going to go ahead and do this. One of the first things that JT talks about is the importance of understanding what we're really talking about, and he cares greatly about pseudoparalysis. And I think if you look at pseudoparalysis, we need to make sure that we're talking about the same thing each time. If you look at this, there were 16 studies, six different approaches, non-op, muscle transfers, RSA. None of these approaches worked in reversing this, and so what really is pseudoparalysis? And so if they all work, what's really the right approach, and how should you do it? Most differentiate based on severity. So is this rotator cuff a functional cuff tear or not? And that's the big issue that we have to decide. If it's functional, then it's a pain problem, and I think many of the options that you've heard from here are available. If it's non-functional, then you have a much bigger problem that you need to address. So what do you do here? So this is one of his patients here. This is a rancher. He's 65 years old. On his left side, he's able to actively elevate his arm. Functional. On his right side, he's pseudoparalytic and can't do anything. And so if you look at his right shoulder, he has a massive tear with DJD, grade three to four guttale with no muscle, and as JT says, if there's no muscle, there's no hope. And so an SCR is not going to help this guy. On the left side, though, he's got a massive tear, but he still has good motion with little atrophy, and in that case, he's got good muscle, and SCR is a good option. So that's when we're talking about doing it for this piece. So in his hands, what he's developed is this very eloquent treatment algorithm, which makes sense. So we start with the massive rotator cuff tear that we've all talked about today, and then you make a decision based on whether they have arthritis or not. If they have significant OA, easy decision. Reverse is the right way to go. If they don't have significant arthritis, that's where we have to decide, and are they young and active patients, or are they older? If they're older, even in the face of a massive rotator cuff tear, reverse appears to be the right way to go. So now we're kind of coming down this left side of the algorithm, and we're looking at the young, active individual, and then the next question you need to ask yourself is, are they functional or not? If they're functional, any of these options that we've talked about today probably make sense. Some people can work on using a biceps as an auto SCR, or work on PT to try to build up their muscle. The challenging ones are the non-functionals, and that's where this SCR fits in. If there's a live muscle, then an SCR makes sense. If the muscle's dead, it isn't going to work, and that's where the lower trap transfer that you just heard about from Dr. Garagas makes the most sense. So how are you going to master this procedure if you choose to do it in the first place? So the first thing that you want to think about from our lessons learned is your exposure and your visualization. One of the critical things that you need to think about is keeping any intact cuff that remains. You want to use that rotator cuff, particularly posteriorly. You want to expose your glenoid. You want to get all the way down to that coracoid brace and see where the coracoid root is in the middle so that you know what you're dealing with, so you're not going to have anchor penetration. And then posterior glenoid, you want to know where that cuff ends. Your glenoid anchor positions are also critical. Three anchors from three separate portals. Your anterior anchor comes from the anterior superior portal. Your posterior anchor comes from the posterior portal. And your middle anchor, which is what we're showing here, comes from that superior or neviser portal. And if you put that middle anchor in from the middle portal, then you're not going to penetrate the glenoid surface, and you're going to be more effective. Now we have to pass our graft. So what we want to do is get all your stitches in the graft exteriorized, and then you want to basically bring in just your middle stitch. You can then use a knotless anchor in that middle anchor, and now it just becomes almost like a standard rotator cuff. You're just passing sutures the rest of the way. And so you can pass one stitch at a time, begin with the middle, then go anterior and posterior, and then you're going to go ahead and fix it laterally. The SCR also needs to be what we call an extension graft. So when you pass your graft, you put the sutures into the graft as well, these mattress stitches. So you're going to fix the graft laterally to the tuberosity, and then you have these extension stitches. And you're going to pass these now through the intact and native rotator cuff, which is going to be critical to success, because you want that rotator cuff incorporation to get your most successful outcome. You want to then turn your SCR into this extension graft. So those middle horizontal mattress stitches are now being passed through the native rotator cuff, and now you're going to get any firing muscle to continue to give you benefit. And so theoretically, then, your SCR is fixed on three sides, particularly medially, laterally, and posteriorly to make it most successful. So in summary, prepare, prepare, prepare. This can be a game-changing operation, but you have to have the right patient and your indications are critical. It's a very technically demanding procedure, so make sure you practice it. It's a good opportunity to go to the OLC. And just remember that evolution is certainly necessary for us to continue to develop this procedure. Thank you very much. Thanks, Dr. Tokish, for his insights. So Dr. Hartzell's next. We're going to go to the end of the road with a reverse and maybe come back. Good afternoon, everybody. Thanks for sticking around, and thanks to the planning committee for this interesting talk assignment, Do All Roads End in a Reverse. I do have some financial disclosures that you can find in the meeting material. Cognitive bias has come up in the meeting. This is an interesting book, specifically relating that concept to medicine. I got onto this book a couple of years ago because we were looking for ways to explain some bias that we saw in the way that surgeons were planning reverse shoulder replacements. Interesting to think about why things appear to us in certain ways. So you might have seen this optical illusion before. The two orange circles are the same size. I can tell you that, but everything inside of you makes you want to believe that the one on the left is smaller and the one on the right is bigger. So that's called the anchoring effect. Cognitive bias, it's a big deal. And unfortunately, just knowing about it actually doesn't solve the problem. We can't eliminate it from our thinking. We inherit a lot of biases from our days in training, religious thinking. Like when I was with Mark Frankel, reverse is the answer to all massive cuff problems. Why would you spend hours and hours doing soft tissue reconstructions when you can just put in a reverse and go home early? And that's going to solve all your problems. Dr. Burkhart, no cartilage should ever be cut out of a shoulder. Reverse is the instrument of the devil for massive rotator cuff tears. So who was right? What have I learned in my practice? Do all roads end in reverse. Another source of cognitive bias is called the framing effect. So it's kind of interesting, actually, to think. I'm using up all of my time, actually, just talking about the talk title. But I'm doing that on purpose because it's important. So if you look at this nice picture that I found, you can see all of the roads coming from the land of cloudy disasters into the sunset of the glorious reverse that's going to solve all of our problems. So we know that's not true. The framing effect's interesting. So in this study, people were asked to value the amount of ice cream independently in these two situations. So think about it. What looks more valuable to you, the eight ounces of ice cream that's served underfilled or the seven ounces that's overfilled? We tend to overvalue things for lots of different reasons. But one is that we think that reverse is a panacea. So do all roads end in reverse? Is that a one and done operation? Should we think about it in that way? We know not all roads end in reverse because not all reverse is even in reverse. Some reverses end in resection arthroplasty. Some end in hemi arthroplasty. Some just end in poor outcome. So when I was with Mark Frankel, he assigned me the job of trying to figure out. He was under the impression that that happened more than he wanted to. And so he said, we've got to figure out what are the factors that are associated with no improvement in this operation? Almost one in five had no improvement in his practice with doing reverses for massive rotator cuff tears. And then you've got to think about the complications also. In a very mature arthroplasty practice and Dr. Frankel's practice, 12% major complication rate. People get better, but you're subjecting them to that risk. We know that arthroplasties have a survivorship, about 1% cumulative risk. These are gonna fail at some point. If the patient lives long enough, we're getting better at revising reverses. But hidden within even the patients who are surviving are a lot of failed ones. You get unsolvable problems with reverse shoulder replacements. So I don't mean to dump on reverse shoulder replacements too much. I do a lot of them in my practice. But to really answer the question, we need to know the long-term results of these soft tissue operations. We don't know that very well. We have a little bit more information now, long-term follow-up on just standard rotator cuff repair. In this paper, massive rotator cuff tears at 20 years. Actually, very few were revised to reverse, and not that many needed further surgery at 20 years. In my practice, I do use a reverse for massive rotator cuff tears. I try to reserve these for the worst tears. We presented this data at the meeting, and it's submitted for publication. For me, these are patients with pseudoparalysis. Most of them have had failed rotator cuff surgery. They have high degrees of fatty infiltration, and other poor prognostic factors for soft tissue repairs. But even in my practice, you see about the same as we found in Mark Frankel's practice, 13% major complication rate. So it's a serious operation. So we'll see what the future holds for these soft tissue operations. Thanks to Anna, the research committee, we're gonna be studying clinical and radiographic follow-ups of dermal allograft SCRs at five years. So hopefully we'll have that information next year. So in conclusion, do metacognition. Think about your own thinking. Think about bias. Think about how we're presenting problems and solutions to patients. Reverse is not a panacea. Joint preservation, I am more enthusiastic about than ever. We have so many tools for this, and so I'm really careful in my practice to try to offer that to most patients and reserve reverse for the worst problems. Thank you. Thank you for that highly cognitive talk there, philosophy. So next, we're gonna end it, even though the reverse was the end, we thought, but then there came the balloon. Joe's gonna finish it up, and then we'll be open for some questions. Thanks for having me. Thanks to the program committee. If anyone has any nitro, I just ran over from ASTS. Could see some nitro paste. So the balloon spacer, short-term bailout or long-term solution? All right, disclosures listed in the AOS book. So short-term bailout or long-term solution? Short answer, yes and yes. I know some of you are saying, I'm full of it, Abood. You're right, sort of, but this is how we figure out new technology. So it's a unique technology, which may change the landscape of how we manage massive irreparable rotator cuff tears, but it has, I think, a focal indication. So it's important to be informed about this topic, and obviously, all of us here deal with patients who have rotator cuff tears. Not gonna belabor this, but they're obviously very prevalent. And this is basically what usually happens. You got a nice relationship between the cuff and the deltoid, and everyone's happy. Then you get this, boom, pop, acute tear, unbalanced. Now we got, you know, massive problem here. But then you have this chronically adaptive state. You're not sure exactly why it's working, but it is. They're missing some parts, but things seem to be working okay. And then all the therapeutics we're talking about are trying to do this, rebalance that elephant so we can raise our arm in a way that's meaningful and not painful, right? We're trying to do that in the simplest way possible, with the least amount of invasion to the patient and pain. So we know there's many factors. I'm not gonna belabor this. Everyone knows this stuff. Potentially modifiable ones, and then there's surgical factors. And here's the problem. You're in here, this is actually one of my patients. He was 33 at the time, and this was about 15 years ago. This is a bad problem for a patient of that age. And I'm not by any means espousing to be a hammer and nail here. I think you have to have multiple tools in your belt because you need to go into surgery armed with whatever solutions you may need, so you gotta be ready for that. It's a goal with any procedure. I think we'd all agree if we can get a permanent solution, that'd be great. But nothing's permanent except death and taxes. Can it be converted easily? Well, I would argue that most of these can. Tendon transfer may get a little bit messy. Easy to implant, I would say nothing's easier than the balloon as far as implanting. I'm not saying that's why you should always use it, or use it, I'm just saying it's pretty easy to implant. And easy to remove? Well, it disappears, so it's kind of self-explanatory. This is the in-space balloon device, and the study, so there's been 30,000 done in Europe. It's completely bioabsorbable, so after a year it disappears. And 30,000 cases done in Europe, and it was released here in July of 2021. There's increasing biomechanical data to explain to us how it theoretically is working at time zero at least. And there's some literature getting better to show what it does and how long it's maintained. These are systematic reviews looking at patients up to approximately two years, and looking at their CASA scores and ASCS scores. And then there's the Pivotal study, which will be published in JBGS later this year, which was a pretty large undertaking. It was about a seven-year study. Started in 2016, FDA IDE, multicenter study. These had to be patients who had intraoperatively irreparable superior rotator cuff tears. They had MRIs at week six at one year. These are all the centers that were involved. And if any of you have been involved with an IDE, you know it's very rigorous. I always say it's like having the IRS live at your house. You have to have all these data points to follow these patients for two years. It's probably what it is, I think, the highest standard of science that we can conduct. And it was an interesting study to be involved with. These were all patients over the age of 40 in this study. They had to have failed four months of non-operative treatment. They could not have severe OA. They had to be able to elevate their arm to 90 degrees. These are all important things that I'll reiterate at the end as far as indications for using this. And this is the whole pathway as far as the data points that we collected. And this is the two-year data. There was 162 patients, 83 in space, 79 partial repair. You can see their mean range of motion and forward elevation at two years. Improved in both groups, meaning one group was either a partial repair and the other group was a balloon. There was no crossover. There was no balloons with partial repairs or anything like that. So you can see their forward elevation improved. It was statistically significantly better in the in-space group than the partial repair, but both did better. You can see their Western Ontario rotator cuff score also improved at a good clip at two years and their constant scores. VAS scores improved. Overall, ASCS scores improved at two years. And then when the FDA looked at this, they did subgroup analyses. So initially, we were told 40 or over as far as age cutoff, but then they decided to start to split the database into different age groups. And the only age group that showed statistically significant improvement in the critical areas of work, ASCS, et cetera, was in patients over the age of 65. But there was a trend towards significant improvement, but wasn't borne out based on a limited number of patients under 65. So in my opinion, this is a well-tolerated procedure. It had similar adverse events as far as partial repair and balloon. No device-related events. Five patients in the two-year study converted, three in in-space, two in the rotator cuff repair group. The average implantation time was about four minutes. This is the first patient I ever did in the United States, for me. 63-year-old patient. He had a previous cuff repair failed. Three years prior, he had the cuff repair. This is what his x-rays looked like. Fairly well-preserved articular surface. Proximal humoral migration. Severe atrophy, with Goutelier stage four on the sagittal views. This is what it looked like interarticularly. You can see cartilage looks pretty good. Subscap in the middle there is intact. And this is the implantation of the balloon. There's a protective sheath. This is going in. I'm putting it in from posterior, so I'm looking from lateral here. This is the protective sheath. And then you withdraw the protective sheath. These come in different sizes, which is not the point of this talk. And then you inflate it with saline. And then you inflate it per the guidelines for each balloon size. And here you can see the balloon unfurl. You can do concomitant procedures in the study. You could have done a biceps tenidesis or tenotomy. You could have done an SAD. You could have done a DCR. You could not have touched the cuff if you were putting a balloon in. You can see I left the biceps here, which is faux pas in many circles, but I did. This is the gentleman at two weeks out. What do you do? This is the gentleman at one year out. And I show this because I actually have six-year data on this guy. And you can see where he's at one year out. He's going to raise his hand. He's a little shy here. Come on. Go. And then this is him at five years out. So you can see now it's in COVID. See? It's not doctored. And this is him now at six years out. I started to decline. This is him at six years out. The question was, is this real or not real? Is it delay or future? And you can see where he is now. So now when he raises his hand, he can still raise his arm overhead. He's a little more deliberate, a little more careful. He's having pain. He actually opted to have the balloon done again. So this is the only patient that I know of that had the balloon twice in the United States. So he had the balloon a second time in the fall this year. You can see his X-rays. Still pretty well-preserved articular surfaces. You can see his MRIs. He's got some increase in his atrophy, but no significant progression of arthritis, which is a little surprising given it's been six years. And oftentimes, we do see some progression of arthritis. You can see his sagittal views, his atrophy. He's probably progressed a bit more in the subscapular region. And this is his dry scope. This is when I ran into his shoulders. Biceps are still there. See? Told you. I didn't cut it. There's nothing really that you can see there. It's all gone. Cartilage surfaces look pretty good. And so I proceeded with putting another balloon in him. And he's now approximately. So I guess the bottom line for this is we'll see. I'm not sure. Hopefully, it's something that's going to have a huge benefit for our patients long-term. But we'll have to see. I don't think this should be balloonamania, just like it was early on, reversomania. I think we have to be prudent in our use of it. Thank you. Great talk. We'll question Larry David after this. We have a little time for questions. If anybody has questions, please step up to the mics. And we'll be happy to address them. I'd like to start off with asking Mike O'Brien a question about augmentation. There was a recent article in Shoulder and Elbow that had some concerns with stiffness after patch augmentation. And I was curious whether you had any experience with that or had any problems with stiffness after that. No, I haven't. But I've seen some of that paper. And it's been reported. And I'm not sure if that's just an inflammatory response in the setting of you're talking about with the collagen implant, not dermal allograft. So reports of stiffness after augmentation with the collagen implant. I had one patient early on that had rheumatoid arthritis. And so I was wondering if that was an autoimmune process going on, causing some stiffness. And we even thought about scoping her to take it out. But we waited it out. And it did not look like an infection picture. But she was getting pretty stiff at four weeks. And by six weeks, it was starting to get better. And then by three months, she was back on track. So I have seen that report. I haven't had too much experience with it. I assume it is an inflammatory reaction to the implant that's causing it. Yeah, fair enough. Has anybody else, any other speakers, had any experience with stiffness after this? We've had, I've had three. And one of my partners has had two, where we've gone back. And there's just a significant inflammatory response. Staples are floating around in the graft. There's sub-deltoid adhesions and so forth. It's almost like, I wouldn't call it adhesive capsulitis, because it's generally extra-articular. But yeah, I have seen it. I think you could change any of your protocols post-op, in terms of movement or in terms of anti-inflammatories. Anything else you might think or consider, because you have the expertise? I would just change techniques. That would be me. Yeah, because I think if you're using it just to repair a partial thickness tear, which is also described, then you can move them pretty early. Because really, after a week in a sling, you can get them moving. If you use it as an augment for a massive tear, then I think you still have to move them pretty slowly. So in my experience, I'm a little more hesitant to do that in someone with autoimmune disease, like rheumatoid arthritis. But maybe Lou has some experience. Yeah, so in the database, we had 210 patients with full-thickness tears. And three had stiffness. Two had bursitis. So there's a distinction. Most of the complications are related to re-tearing. We had 11 re-tears. So the bursitities are very painful. The bursa is swollen. It happens at about three months. The stiffness occurs earlier, probably an inflammatory reaction, as you said. We don't know what causes it. Maybe it's related to the cross-linking in the graft. Maybe it's related to the PLA staples. We don't know. It is something that you need to tell your patients about. It's a low possibility, but it can happen. Thanks, Lou. Brian, I'd like to ask you, you had a great talk. I'd like for you to take us through, when you evaluate a patient for biologic augmentation of their cuff, what are the factors you're looking at? And how do you talk to the patient in the office about augmenting them? What kind of information do you give them before you do this? Sorry. Are you referring to something we might inject as an adjunct or as, say, a dermal augmentation? Well, they each have their own individual consequences. So dermal augmentation is a procedure that there is no financial aspects that we have to really discuss. But we are conscientious as far as where we do it and what setting and with what carrier, because the system that I use adds incrementally about $3,500 to the cost of doing business. And that might be really relevant, depending on the environment you operate in. So in our ASCs, we have several of our carriers allow allograft codes. So that's helped to soften that a bit. From a surgeon billing perspective, I've been billing an unlisted procedure and kind of open for the best. Or I will do a 22 modifier and just say it was incrementally more difficult for x, y, and z, something like that. I don't honestly know if we're getting paid, but I will tell you that this takes about 10 to 15 minutes to do the operation, and it's not a difficult surgery anymore because we're not shuttling sutures down. I'll show you, we'll do a case in the case-based discussion to show you how easy it really is. So that's for that, but as far as discussion with the patient, my early concern was if it fails, because this is a paradigm shift to something that doesn't go away, versus the inductive, bio-inductive patch, which does go away. So I'm personally more interested in permanent conformational change in the end construct, because the biology sucks to begin with, and it's gonna suck at the end, so let's just make it not suck so bad, you know? I mean, it's just, it's a really bad biology situation that I don't think time zero is gonna do a whole lot, quite frankly, and I think we need something that permanently integrates if we're interested in doing that in them. So I'm paying attention to these other factors, that's why I really do think that study was interesting, that Rohy index to start helping us become a little more objective about this. So I'm less worried now, because we've seen them integrate by MRI and haven't had one yet that has caused a problem with mechanical symptoms and so forth. It's only a one millimeter thick dermal graph, it's not the SCR graph, which is three. As far as biologics, it's a much longer discussion that, you know, we stay away from the word stem cells, we tell patients that a miter could help, that there's no clinical downside, that there are, we cite the studies, but we say that, you know, we're not, it's not conclusive that it makes a difference, and if money doesn't matter, then this is something to do, but if this is a financial challenge for you, then let's not even talk about it. So it's a very soft sell, if you will, but they pay out of pocket for PRP and or bone marrow aspirate, and then they ask which one is better, and I don't really know the answer to that. There is bone marrow aspirate, actually you could argue that there is an elevation of five to seven fold increase in PRP in bone marrow aspirate, so maybe you get something else. So I think that patients who are willing to say, let's do anything and everything possible to prevent a retear, they might be interested, but you have to sort of be very careful. There's obviously the ethical considerations of how you present this to the patient. All right, Dr. Field, do you have a question? Yeah, just a quick question, one quick comment first. Is it okay, Brian, if I use that with my own patients? Say, I just hope that you don't suck so bad. No, but that's a great point. Just to change the subject briefly, I want to ask Joe a Buddha question about the balloon. You know, Joe, you showed great slides and good outcomes for the balloon versus partial repair, but now that you're free to do what you want to do with these patients, do you combine partial repair with the balloon, and do you have any data to support that they might be, in fact, advantageous when done concurrently? So the person who has the most experience with that is Laurent Lafosse, but I, so, release, I've done 14, and I can tell you probably a third of them have gotten some partial repair. The other two-thirds have not, and partly because, A, I keep my indications tight. In these patients, you don't want to be doing a lot of debridement and clean-out, because that's where you get yourself into some issue of potential balloon migration, because, again, you're putting a balloon in a subacromial space. Subacromial space is a high-pressure area. You put a balloon and saline in it, and you start cranking the arm around, well, of course, the balloon's gonna want to go somewhere else if there's less pressure in that area. So if you open up a bunch of areas, like, clean out your supraspinous fossa, all that bursa in that area. But for all of us that go into these, you know, chronic tears, they have kind of this pseudo capsule around their head. So if you put it in that pseudo capsule, I find that it fits nicely, and it tends to want to stay there. So, long story short, I don't, I try not to combine something else with it, unless I have to, like, if they need a biceps tenodesis, etc. The good news is there is a HCPCS code coming out, my understanding is, end of this month, which will provide hospitals reimbursement for it, because it is costly, and I think some people have been combining a repair with it to offset some of the cost of the implant and get some more reimbursement for their center. Can you tell us real quick how you deal with the reimbursement issue right now? I know they have a HCPCS code, or they have, but that's not associated with ARVUs or anything like that. So, do you do it at the hospital? Yeah, I do it at the hospital. Our hospital has allowed a trial, and they're kind of reevaluating after the trial, looking at the whole episode of care, just to see what the cost, you know, cost analysis is. Yeah, thanks. Okay, so we'll just finish up with a couple of quick cases, maybe drive some of the points home, and appreciate you all staying. It's been a great meeting. Congratulations to the program chairs. So, I put three cases together, we'll get through, if you could just switch over for me. Oh, okay. All right. Okay. So, that was the panel, but you guys are absolutely all welcome to stay up here. This will be like an OSET meeting, okay? So, a couple of cases. I'll just start out with this one. If you could turn the volume up, that would be great. Is that able or no? All right, do you want to give me a thumbs up or not? I can just, I don't need it if we can just, I can just explain the case. Yeah. What's that? You like that? It actually looks like it covers his face on my computer, but it clearly doesn't look like it's doing a good job there. Talk about suck, right? Okay, so this is a 48-year-old running down the labor road with shoulder pain. He had a previous cuff repair and a tinnitus 12 years earlier. He's been largely asymptomatic, but he had recent worsening, including night pain and disability, and he wants to get stronger and have less pain. And his exam is pretty straightforward. He's not by any means a disaster, and you can see the word, we've talked about conservative care, we've elected for surgical care, right? So, he's weak. He's not, as I say, clinically a disaster with this, and his primary goal is really to get more function and less pain. He's got no significant findings on his radiographs, and his MRI is actually, in my opinion, not terrible. I think the poignant features in this case were that he had a previous repair. He's otherwise pretty young. He's a laborer. He's got good muscle quality, no significant fibrous replacement or atrophy. So, and that just gives you static MRI. So, Mary, why don't we start with you? Is there anything you might be thinking in a revision situation that you might, without an incident, without a report of another trauma? Yeah, I mean, he's a young, healthy guy. No trauma. I don't know if he has any contributing medical problems, diabetes or whatnot, that you would worry that could potentially contribute. It is concerning that he's young and just had another atraumatic cuff tear. Okay, so from a surgical perspective, anything you might, Larry, would you be thinking about anything different or just go back, do the same thing again? And I don't have any facts about his previous repair, those 12 years earlier. Yeah, well, you know, importantly for me in my practice, he just no longer has a biceps. It might be a real consideration for me in a revision repair, but that said, you know, I really worry a lot about his weak, his low level of active forward flexion. That's really a big red flag for me. So, in that situation, I'd probably tell him I'm hopeful to repair it. I may supplement it and I may even do an SCR if it's much worse than I think, but based on the MRI, I suspect that I'd be able to do a repair, probably medialize a footprint, plus or minus supplementation. Okay, so, hey Brian. Yeah, please. This guy's got a subscap tear until proven otherwise. Okay. I mean, fair enough. But revision repair, it was fatty, commonly missed, common cause of revision. You got to really look hard for that. For sure. Yeah, this one did not, but you're absolutely right. That's, you got to look for all sources of potential failure, or certainly all sources of disability. Why don't we just very quickly, just so we get varied opinions across the panel, indications for augmentation with dermis. Okay, so we'll just stick to this as a potential solution. So, Robert, why don't you start with you and just move left to right. For dermis, for me, it's when there's significant collagen loss, a short tendon revision situation. Okay, and if people say the same, if you have the same opinion, you can just move on. Lou? Yeah, I mean, we're looking, you're looking for structural replacement with a dermal graft, as opposed to just pure augmentation of the healing process. Okay. It's a possibility, but it looks like it's repairable to me. Yeah. Okay. Yeah, no, I agree. In this case, definitely a try for a primary repair, but use the dermal allograft for if there's poor collagen, as we touched on. Grant? Yeah, same as Hartzler. A revision, any revision, I'll consider it, and then if there's collagen loss. Okay. Same, nothing else. It's just that the tendon's not very mobile, and I would be more likely to add it. Okay. In the revision situation, purely for me, I always try to augment that somewhat because of the decreased healing milieu. So, in this case, I would use an implant here, a bioinductive implant. So, Lou, how would you differentiate the sort of value proposition of a xenograft collagen versus dermal graft? How do you think about it, you know, intuitively, in terms of what they each bring to the table? Well, once again, you have to be able to get a good repair where you think you have a reasonable repair, a good chance of healing, to not require any bridging kind of effect with or structural addition with a dermal graft. You know, this looks like a pretty repairable lesion to me, so I'd get it back, do my typical repair, and then augment it just because of the decreased healing ability in a revision situation. You know, you have decreased blood flow, you have increased scarification. So, these are things that contribute to the higher rate of non-healing in a revision situation. If you look at, you know, Buddy's study with Thon, I mean, it's a level 4 study, only 23 patients, but they had 100% healing in the primary repair arm and 89% healing in the revision situation, which is way better than the literature. Mike, what do you think as far as, you know, differentiating dermis versus a collagen graft? You know, I think they are very different biochemically, they're very different structurally, so I sort of think about them different, not interchangeable, but I'm just curious what your thoughts are given your talk. Yeah, I think it, for me, a lot of it has to do with the tendon mobility at the time of surgery. So, if you have a nice robust tendon that's mobile, that you can do some releases and get it over the tuberosity without much tension, then I'll do the collagen augmentation. If the tendon looks like it's atrophic with less collagen, kind of like Robin Grant said, or if it has trouble reaching the tuberosity, then I worry that that's kind of asking a lot of that collagen implant, so then I'll do a dermal augmentation to just give it a little bit more strength and more collagen, especially over the tuberosity interface. Okay, all right, so obviously he did well, I wouldn't be presenting the case otherwise, and he, you know, he feels like most rotator cuff repairs feel. I think the issue now is all about anatomic integrity, and that's what we've been most interested in, and we're following all these patients prospectively. I think the middle picture, pre versus post, is what we're most used to, accustomed to seeing, and I, you know, I think we just have to continue to follow these patients, but this concept is not new. The new thing about this is just it's easier to do, and it's extremely efficient, and the fixation device is very, very satisfying, and the lateral fixation is basically using a single anchor, knotless anchor, anterolateral, posterolateral in addition to the construct, but other than that, it's not particularly novel. Brian, sorry, before moving on, did you change his post-op rehab at all? No, I will let people do passive range of motion out of the gates. I don't take great comfort because I've put something in there to change things, so I still go relatively slow with active stuff, but I start passive immediately, and closed chain immediately, and sling them for about four weeks-ish, but if they're really tentative, then I may go six weeks, but, and may delay active strengthening, so, but I don't use this as a night to say I'm gonna go faster yet. I just don't have that. It may be able to, but I just not, not really there yet. Is there sound or no sound? Sound or no sound? Just, if you just, just tell, you have sound? All right, good. Maybe, sorry guys. So, there's no sound. Okay, thank you. So, this is a 53-year-old. She had a debridement in 06. She had a dermal graft in 06. I think the technique that you saw, which was a parachute in and so forth, and she did pretty well from this, and then she had symptom onset in May of 20. She had pain and discomfort, loss of function. She had physical therapy, non-surgical management, and her symptoms did not improve, and then, again, like many, she wants to get through the night and have more function and less pain. You know, we talk a lot about this concept of pseudoparalysis and so forth. I think everyone would agree this is not pseudoparalysis, but I think one of the interesting things about pseudoparalysis is that, especially as it relates to, you know, what SCR can and cannot do. Grant Garagas and I were talking on a little sidebar, you know, this concept of good muscle versus bad muscle. I mean, it really is sort of a either reverse parachute or tinnitus type phenomenon, and I'm not sure the dynamic aspect is relevant other than the fact that they may have less pain and more function. They become adapted, sort of like what Joe was showing. I love those, the see-saw, because that concept is why six and a half million people walk around and are functionally just fine, because they're in balance. So, she really has problems with the extremes of motion, and she's weak, but you can see she's clearly not pseudoparalytic. X-rays look okay. Maybe you get a sense of some early proximal migration. Here's her imaging again. So, she was a previous cuff about seven years ago with a dermal augmentation, not as an extension graft. It was just laid on top. So, that's just give you a sense of what her imaging looks like, and unfortunately, I don't have it medial, but you know she's gonna have a lot of atrophy there, and her subscap was intact. So, I guess the first question, you know, we don't, we're not, we used to talk about, we used to talk about repair and even partial repair as doing a great job for our patients, and I think it's a bit stunning how we're talking about a lot less these days, because this still is a very good option. So, this is a gentleman who I followed for almost 10 years and ended up repairing, and very poor tissue quality, and he was pseudo-paralytic to begin with, with hornblower and drop arm and so forth, and we just did a side-to-side repair and put an anchor laterally, and within three months, this is what he was doing. So, I just, I say this because I think we, we, we ought to not forget that repair is possible, and the literature is actually quite supportive of this, but to that end, Larry, you know, are you doing anything different these days? Do you still do repair of massive tears, or now we have all these, these sexy techniques? Are you jumping right to something else? No, I do a ton of massive repairs. Interestingly, there wasn't a talk on it today, but I think it's, it's the vast majority of these, how I manage these surgically as I repair them, you know, routinely. Okay, so in this case, Mary, she, we're gonna say nobody's home, all right, and I don't think there's, I'm gonna tell you, I did not think there was anything to repair there, or there would be any repair, so discussions, and this is where I think Robert's talk was interesting, because you can have the same pathology but make a different decision, and also lots of ways to get this right, but in your treatment algorithm, you know, what are the patient-related factors? Let's say we know the disease is super-infra, and we'll say it's irreparable, either functionally or physiologically, right? So what are the factors that you think about of saying SCR versus maybe reverse? Yeah, I mean, in this case, she's relatively young. She's 53 years old. She does have mild arthritis, but obviously way too young to consider doing a reverse, and so, I mean, I think in this case, an SCR would be appropriate, but going in there, like obviously trying to repair what you can, and then doing the SCR, I think that that would be my plan in this case. Joe, do I need to put balloon in the snow as one option? Joe's gone, but I think I would consider a balloon for this patient. Consider it. I mean, I think the reason to throw SCR into the mix is because of the age of the patient, and as you can see from that case that Joe showed, you know, the balloon does go away, and I think it's likely in this age of patient that they're going to return to a symptomatic state, and so if you could get a soft tissue reconstruction that would heal, that would be good. I mean, this patient is set up for a dissatisfied reverse. You know, she's got full range of motion. It's just a pain problem. Grant, what about, what are the features of her physical exam that may steer you towards or against lower trap? Yeah, so first of all, you should like a HMATA 2 x-ray there with a narrowing necromia humoral interval, so I want to try to do basically a sulcus sign maneuver, have her relax, and make sure that I can get her arm down to a normal station. If that humoral head is stuck up there, I really had very poor results of getting that back down and doing a soft tissue procedure, so that's one thing. As far as the lower trap versus an SCR, really it's going to be a question of, you know, what she wants out of this. If she wants pain, I think an SCR is perfectly appropriate. If she's like, I really want this external rotation strength, right, that doesn't look like it from the case you presented, though. Yeah, I think she's a, for me intellectually anyway, she was an easier one for SCR given all these factors, and that's what was done. I agree she was a HMATA 2, not super high demand, but really had specific needs, and her big needs were pain. So yeah, that's what we did. It was SCR, and I think this is the one point I want to address, and JT's talk, he's not here to defend himself, but you know, I think this concept of good muscle versus bad muscle is an interesting one, because I think what he's leaning on is that he repairs the remaining supraspinatus tendon, or supraninfra, to the graft, right, and I'm not sure that's really particularly dynamic, because you're fixed at the superior glenoid, and I don't know why that's the criteria. I actually think SCR can reverse pseudoparalysis, especially when it's associated with pain, and I've seen in my own patients, so I think it's absolutely doable, but there might be some intrinsic connection to pain, and I've been pretty impressed with that, but we've also found that if their subscap is compromised, much like was pointed out before, this is that this is one of the biggest risk factors when subscap deficiency, even if you fix it, but in our series they didn't do very well, even with a fixed subscap. I had a great video of her, but we're not going to show it, so at any rate, just any final comments about SCR in terms of return of function, and we can close out the session. That's one that I, following up on what Grant said, I would lean towards a lower trap transfer on that, because I think, like you mentioned, her atrophy in her infraspinatus was probably bad, and she looked pretty weak in her infraspinatus, and so I think I would add a lower trap transfer to have a active muscle contracting, and then try and repair her native cuff back to that. What about an SCR with a lower trap? I've never done that. What? Yeah, she was working, yeah. It's going to give you that infraspinatus strength, because her infraspinatus wasn't working. She had a lag sign at her side, and when Brian pushed on her arm, she was weak, but I think your lower trap is going to give you better external rotation strength at the side. Some folks say that if you have a hornblower, you should do a lat transfer, because the line of pull is different, so I think a lower trap transfer is good for external rotation. Can you start the video for a second? I just want to show your function. Anyway, yeah, no, I think those are all, this is clearly COVID. I zoomed her post-op evaluation, but I don't, if you just maybe fast-forward a little bit, you're not going to have any volume. It's Christmas time, but she was really happy functionally with this, and she would say that her strength came back, and she's doing everything, so I can't explain why, to be honest. I think there's a lot we don't know. This is the one we could have left without the sound, I guess. You guys can't un-hear this at the end of this session, sorry. Hey Brian, can I say one thing about strength and lower trap? Yeah, please. I like what Jerry Williams says about tendon transfers. The people who need it the most benefit from the least, so I've done lower trapezius only in patients with huge lags, and I have not been very impressed with their getting back their strength, and I feel like a lot of patients with lower trapezius are like this, that they get pain relief from the surgery, and they rehab their teres like crazy, and I'm not, I have not really been convinced in my patients that it's improving their strength, the tendon transfer that much. You lose the greatest strength, the lower trapezius is one-third the strength of the infraspinatus, and you're bridging it with that graft. To me, I mean, I'm having a hard time believing that it's coming from that. Yeah, those are great points. Okay, I think we should wind this up now. Thank you very much, and safe travels.

surgical options

shoulder problems

rotator cuff repair

massive rotator cuff tears

biologic collagen implants

lower trap transfers

irreparable cuff tears

superior capsule reconstruction

reverse shoulder replacements

tendon transfer