to start our case discussion for CUF. Thank you. It's an honor to be here. Thank you to Michael and Scott. In your program, you may see that it was supposed to be Jeff Abrams, and so it's not easy to be Jeff Abrams, but I did bring a pocket square just to be sure that I have his mojo behind me as we get started. We have an incredible panel, and on top of that, we also have incredible moderators who I'm going to enjoy bringing into this panel as well. So we're going to go ahead and get started. My disclosures are available on the website. So our first case is a 49-year-old female animal control officer, so she takes a meanie out of the play already. We have 18 months of shoulder pain and weakness after getting pulled by a dog while working. She's got night pain, ongoing weakness, and on exam, she has 140 degrees of active forward elevation and abduction. She has 60 degrees of external rotation. She's weak with forward elevation and external rotation testing, no external rotation lag and negative horn blowers. And then here's her x-rays. So she's 49, and we've got a tough situation here. So Joe, balloon time? I'd like to see an MRI. Maybe I don't get one, but 49 is pushing it. Yeah, so when you look at the x-rays, aside from that, Lou, where are we going to go from here? I mean, this is a tough problem before we even talk about additional imaging. So young patient, and she's resilient. She's had symptoms for 18 months, right? She already had an injury, so she's going to probably do well with anything you do. She's got a Hamada II. You're going to try to fix whatever's there. I mean, that's going to be my goal without seeing any other kind of imaging studying is to get whatever rotator cuff she has left fixed. And you could use your biceps too, or you could whatever, the kind of grafting you want to do. I mean, this is not necessarily a patient, unless she's a massive, that would be indicated for augmentation. But certainly, I'd be thinking about it. OK. So it's also work comp. It makes it all that much difficult, remember? When she was 49, she's an animal control officer and got hurt at work. So now, when we add the work comp component to this, Pat, do we have any work comp in Oregon? What do we got here? Lots of it. Lots of it. No, I mean, I think that plays in. That may have played into her delay, but ultimately, you've got to treat her the same. I agree, this is going to be a tough one to repair, so you've got to get her MRI, and you're going to be looking at doing something, joint preservation, because her arthritis is minimal. If she's 75, you're going to go with reverse. But at her age, I think you've got to try to do something joint preservation-wise. All right. So she's tried rest. She's been on anti-inflammatories. She went through 24 sessions of physical therapy. She's had two cortisone injections. The last one was six months ago. Any impact, Michael, of those cortisone shots that she's had, when you see what her x-rays looked like to begin with? Yeah, I've become way more conservative with corticosteroids and cuff disease for that reason. I mean, there's basically, every time we get a study large enough to show us, every time you do a steroid injection for cuff pathology, it increases your revision rate, lowers your outcomes. We used to think it was OK, I think, because our studies weren't big enough. It's just, that's a bummer. I mean, she's young, and that's going to really impact her biological healing. Yeah, so this is when she first shows up in my office, after all this is done. So this is what happens, I think, a lot of times on these big cases. And my entire practice is Rohy 7 or higher, it seems at this point. And so, especially now that Dr. Snyder's retired, I get all these huge, massive tears, and so it's really become a bit of a challenge. And so she's gotten some temporary benefit, and Joe, you asked for your MRI, and this is what you get. So now, what are we going to do? And I've tried to pick out some sequences. There's really no surprises here, but her head is really up. We don't see much cuff. What are your thoughts? What are you going through, your thought process, as you're trying to decide how you're going to help this woman? Yeah, fairly significant involvement in superior and posterior cuff on this lady, 49. I want to do something reconstructive, if I can, in a 49-year-old to give her a better shot to last longer. This was 75, I would differ with Pat. This would be a balloon for me as a first intervention before an RSA with that much motion. So potentially do something and augment with a biologic, much like Lou was saying. But this is a tough problem. So Ivan, what are we going to do? You got to make a decision here. You're right. You can say, all right, we're going to go to the operating room. We're going to do something. But how are we going to manage this patient? Absolutely. So for me, I would have a biologic to me. Here is a dermal graft, obviously taught very well by you and Steve Snyder. Good part is she hasn't had an operation before. Also on that Y view, I do see muscle. It does look atrophied. But as we pull it out, it tends to get better. So I think we have a chance to do a repair and then do an augment on top. And if we don't, we already have the equipment to do a nice bridging interposition graft. All right. So 49, as I said, work comp, animal control. She says her shoulder was fine until the original injury. She's been out of work now for a year. She's used up all modified duty available to her. And she says, you know, I really want to go to work. So this isn't Philadelphia, Joe. This is reality out here in Los Angeles. But she's actually very fit. She works out all the time. You know, obviously, she probably hurt her shoulder working out first and it was a second or acute on chronic with her injury. And so, you know, I'm going to give you one last piece of information here. And so this is what she looks like. We know now we went to the operating room. There's her biceps. It's lateral decubitus. So all you beach chair folks, turn your head to the side. And you can see here there's nothing on the humeral head at all there. I'm now going to go ahead and look from the front, which beach chair people don't do. And we're going to look from the front. And you're going to see there's what you have left of the cuff in the back of the shoulder. And now we're going to go up into the subacromial space. You can turn your heads back the other way. And this is what you have. So I've got no cuff medial at all. And then, you know, you can pull back on her. What you didn't know is their MRI was 11 months old because I couldn't get a new one. Work comp wouldn't authorize a new one. So she's actually now worse than what we thought when we got to the operating room. And that's all the cuff I've got. So we're going to run down the line. Lou, what are we going to do? Quick answer. So buddy told me there's no rotator cuff tear that you can't fix. So I'm going to try to fix this. Looks like you can get a good margin convergence. I'm probably going to put the biceps in there also. And then I'm going to put some type of augmentation on top. Rowdy biceps. Joe, what are you going to do? Similar to Lou, a lot of preemptive discussions about never returning to work. And this is a lifelong problem. Pat. Cable reconstruction with a semi-T allograft, tinnitus of biceps in situ, and advanced infraspinatus up to the posterior limb. Tinnitus in situ, so you're just going to tack the biceps down. You're not going to move it. You're not going to transfer it. I'm not going to move it posteriorly like Larry Fields proposed. I've tried that in a few, and I've just been unsatisfied with my pain post-op. I think it's a really interesting idea. I just haven't seen what he's seen yet. Michael. So I actually do the same thing in situ tinnitus. OK, then you're done talking. Next. But I'm going to repair everything I can. But I think if you really want to resist sort of escape, right, it's anterior superior. The acromion helps you posterior superior. So in situ tinnitus is repair, but I'm probably going to help fill in whatever's not repairable with an interposition, a bridging graft. Got it. Ivan. Same. Same. OK. Well, all right. So we talked about all the options. Everybody talked about it. But nobody brought up tuberoplasty, right? Tuberoplasty is now becoming very popular. And what about just trying to do margin convergence, close that medially, and then just put your graft on the tuberosity? Pat. I've done it, but I reserved it for older patients that are irreparable. So for me, that's the over 65 where I think maybe Joe would do a balloon, but I would do the tuberoplasty. OK. Michael, you didn't talk about your lower trap. Is that just because she's female? No. I think she's got her external rotation, so I'm not sure that she needs a lower trap. And I'm going to repair everything I can. So I think I would either I think to me it makes sense to repair her and then bridging graft for whatever's left or repair her and augment with a lower trap. I think both of those would be very reasonable for her. Yeah. And I think that's an important point. I think you brought it up. We do see lower results sometimes in people with those demands. But this woman is really active, and I think it's still a good option. So our choice, human dermal allograft. And the question really is, how are you going to go ahead and use this? And we have real experience with it. And the real question in our mind is, how do we best employ it? Should we be doing bridging, or should we be doing a superior capsular type repair with that? Ivan has shown us that bridging really still has value. And if we look at our experience at SCOE, we kind of have done more bridging than anything else when we look at this. And there's been a big shift towards SCR. At SCOE, between Dr. Snyder, Dr. Burns, and myself, we have the world's largest experience on interposition. And dating back to the 90s, we've done over 1,500 cases. But it's technically challenging, and it remains off-label. But since the advent of SCR, just in the past four to five years, there's been well over 25,000 of these. And so it becomes more of a complex issue. The real issue for me is this fasciae latae comparison that we keep making. A 4-millimeter graft might decrease our subacromial contact, but it's not going to improve the distance. And her head's all the way up. I got to get that head back down. And that was my big concern with our, quote, US equivalent. So here's what I did. So I'm doing a low superpec tenodesis. And so I'm doing a suture anchor tenodesis low down in the groove, just above the pec. I'm going to then take my biceps, and I'm going to pull it back out the nevizor portal to get it out of my way. And in this case, I'm actually going to do a superior capsule because I don't have really any tissue immediately to bridge to that's going to give me any strength. So in this case, I'm going to go ahead and do a more classic SCR, but I'm keeping the biceps tendon. And by keeping the biceps tendon, I have that added tissue over the top. And so different from what Pat was talking about, I actually released it low, not in situ. I'm going to bring my graft in, fixate the graft here laterally, and do kind of a standard SCR style technique. But then I did, I brought the biceps down over the top of it now, over the top of my graft. I brought up the anterior and posterior cuff to the graft, as Lou talked about. And so this is what it ends up looking like at the end. And you can see here, we're fixating it on the tuberosity. I've got a nice trampoline effect in terms of that. And then you can see I pulled the biceps tendon up over the top of the reconstruction. And here's what our x-rays look like post-op. So should I have done something different? Michael, where are we here? No, I think that looks great. I think that's a really good option for her. It was not much to work with, so I think that's a really good option for her. So Ivan, you know, I didn't do a bridge, I did an SCR. Absolutely. So if she had good external rotation with that teres minor, that's wonderful. And it was so much more atrophied, you know, obviously having an MRI, you're becoming like a Canadian. We get MRIs, you know, two years after. So it's very different from what we see. So that's a big point that I want to make is if you're a big gap in your time, get that new MRI if you can, because sometimes you get in a situation like this where it becomes really challenging in terms of what to do. So she's happy. She actually went back to work at 10 months, Joe, no restrictions. And four years later, another dog pulled her for her other side, and she had a simple, straightforward, you know, two-anchor cuff that I fixed, but she's actually doing well four years out. So how do I decide what to do? If it's good quality tissue medially, I'm going to do that interposition to get some cuff control. If I don't have tissue medial to the glenoid, then I'm going to go ahead and do the SCR. And if I can, I add that long head of the biceps over the top to try to reconstruct that acromiohumeral distance, because the three-millimeter issue remains concerning as we do this. So the next case with the time we have left, 74-year-old, right-hand dominant male. He has a cycling accident in December of 2020 in the midst of the COVID pandemic, immediate pain and weakness, but doesn't seek treatment because he's kind of afraid to go to the doctor during this time. His pain persists. He's got anti-inflammatories at home. His next-door neighbor is a therapist, and he actually went to urgent care and got a cortisone shot, but he's no better. On exam, he's pseudopoietic, really, more than anything else. He's got 150 of active forward elevation. He's got normal extrarotation, intrarotation. His impingement signs are positive. He's got weakness, and his belly press and bear hug are negative. And then here's his X-rays. So plain X-rays, really nothing to speak of, you know, head's not up, no significant OA. He's 74. And so in this one, I'm going to give you his MRI right from the get-go. So Joe, where are you going with this one? So tissue quality looks fair as far as the superior cuff tear, but obviously with his advanced age and the chronicity of this tear, I would- This MRI is two months old. So there's no chronicity. Right, but the injury happened a while ago. Two months. So, yeah. I'm sorry, okay. This would be a person that I would consider strongly for the balloon, potentially with a repair first and then a balloon on top. But again, I would think balloon first. So Luke, looking at this MRI, are you concerned that this is irreparable? It's two months old, no previous injury, no previous trauma. Looks like you got tissue well lateral to the glenoid, I mean lateral to the acromion. Yeah, but muscle looks okay. I would sort of, I would be thinking about fixing this, 74, the age would be, I'm thinking more of arthroplasty kind of things if I can't get it fixed. Because I used to work for an Irish roofer named Gallagher, he said, boys, don't do the job too good the first time around, they'll never have you back. So the problem is, what are you going to do for this man that's going to fix his problem and, you know, fix his problem for good, right? So wait a second, I'm a little confused. So this is a guy who falls off his bike two months ago, he's got a very repairable rotator cuff tear, and we're talking about balloons and augments. Michael, does this guy need a lower trap? Reverse, no. He's, yeah, this is, I have no problem repairing people in their 70s, especially if they're traumatic. I think they actually do really well, clinical success rate's really good. Even for large tears at 74, I have no problem trying to repair those. Okay. So rotator cuff, I told him, fix your cuff, you know, no big deal, you can fix this. This is a straightforward rotator cuff repair. And he's like, doc, you know, there's COVID going on, I don't want to go to the operating room, you know. I'm like, well, the operating room's in a surgery center, you're going to be fine. You know, I don't want to fix it. Continued to have weakness, his pain persisted, got to the point where he couldn't sleep at night. And then a year later, he comes back to the office. And so, you know, the question really becomes, now what? You know, what are you going to do with this guy? You know, are we going to go ahead and just, you know, move forward with surgery as we talked about? Ivan, Canada, we're going to, we don't have an option of another MRI, so what are you going to do now? Yeah. So, essentially, we have all, everything on the table. We plan to go in, fix it, hopefully have some graft on the back and deal with it at the time. So, fortunately, I don't live there. Now here's where he is. And so, everybody talks about this happening, but it's very rare that you see it. And so, now where we are here, so Pat, so we're 74, you know, you can give us, calculate our Rohy score for us here and what do you got for this guy? Yeah. So, he's going to have a high Rohy over seven, I think he's going to be about nine. Just looking what I see there. So, his chance of healing is going to be low. So, this depends on his function. If his function is overhead preserved, I'll accept that in the individual of this age and I'll repair as much as I can. If his function is very poor, then I'm thinking about an alternative, such as reverse. Yeah. So, you know, if you look at the muscle in the back, it's actually quite good, right? So, you know, his infra and his teres are still in pretty good shape. And so, you know, even though it looks terrible on the AP view, you know, we had a long conversation and said, you know, what can we do for you? And so, we talked about dermal matrix allograft, you know, augment either a bridge or even doing a superior capsule. But you know, 74, you know, you have to have that conversation about reverse, right? Functionally, he was actually still doing pretty good and he's like, you know, I just don't really want a replacement. So, we get to the operating room again, turn your head sideways, here's what we're looking at. And so, this is the cuff that you have and now we're in the subacromial space and I've got this big hole. So now, I'm in a situation where I've got a big hole, you know, we're going to go ahead and try to go ahead and pull this thing over. And pulling on it either way, can't really get it to move, can't really get it to do anything. So, Lou, where are we going? I think if you, you know, if you spend some time here, interval slide, you could get that back. I think you could repair that. And if you couldn't get it back, then I think you're, if you needed to bridge it, you'd do a dermal. And if you did need to bridge it, then you'd use some type of augmentation. So, he's 74, I'm in my surgery center. If I put a bridge in there, you know, my partners are going to fire me because we're in big trouble right now. Pat, where are we going? I would repair as much as I could and if I can't get a complete repair, then I would put a tuberplasty on there in the center. But I think, I agree with Lou, I think you actually can mobilize quite a bit. And at 74, that's acceptable. Joe? Balloon all day, every day and twice on Sunday. Yes, baby. So, you know, we got to this place and this guy's like, look, I just want something to get rid of my pain. You know, I'm really tired of hurting all the time. And so, you know, we went ahead and I was part of the space group and did part of the initial evaluation. And, you know, it's been challenging to find the right patients for this. And this, to me, is one of those cases where I think it really makes good sense in terms of doing the balloon. You know, it's actually a pretty good option. You know, his x-rays post-op, so I did a little limited subacromial smoothing, cleaned him up. He was in a sling for just one week. His pain is gone. And to me, this is the key. This is where he is six weeks post-op. So he's got full mobility. You know, tell me which side he had it on, you know, and, you know, you can tell it's, he's really done quite nicely. So why not fix what you can and then balloon him? So, you know, I actually put one or two stitches immediately just to kind of close down the gap just a little bit. But to me, this is where we were and I think it was a really nice option. So Lou, I think the issue is if you repair them, then they get a repair and then your balloon is just an augment on top. Like it totally changes sort of how you treat that person. You don't rehab them like a balloon. Their primary operation becomes a repair. So I think like this is the guy that I probably wouldn't repair at all. I wouldn't do anything else, sort of in and out, 10-minute surgery, do a balloon. I think there might be some utility in doing a heroic repair and then putting a balloon on top, but that's a different animal than an augment. Your second operation after that, if you do a reverse, has a worse outcome with a partial repair versus doing the balloon by itself. Why? Again? What was that? Because the data on cuff repairs and then a reverse are worse outcomes versus patients who've had no previous surgery. And the balloon does not leave any remnant scar tissue or subacromial adhesions that we see compared to a biologic tuberoplasty or partial cuff or SCR. We're out of time. Thank you all very much. I appreciate your attention.

rotator cuff injuries

case studies

treatment options

biologic augmentation

joint preservation techniques

work comp issues