Go ahead and get our panelists to come up, and I'd like to invite Dr. Gettleman and Dr. Lowe up to the podium to moderate. Thank you. Well, good morning, everybody. Thank you very much for the honor to be here with our friends from Issacoss and Anna. We've got a great debate and looking forward to talking about everything that they didn't just talk about. So our cases are gonna be very unique and lots of good things to discuss. Our disclosures are available and we have an incredible panel here today. And when we went through, we've got Mike Amini, Sarah Edwards, Albert Lin, Ettore Taverna, and unfortunately, Dr. Abood wasn't able to be here. He had a prior engagement, and so he's not able to join us. So filling in for the balloon is Dr. Murthy. So with that, we're gonna go ahead and get started. Our first case is a 56-year-old studio electrician who happens to be a smoker. He's had vague shoulder pain for years, and then six months ago, he had a dirt biking accident and now has severe pain and weakness. He's got pain at night and he's unable to work. He's pseudoparetic, to kind of complicate it. He's got 120 degrees of active forward elevation and abduction, 170 passively. He's weak in forward elevation and external, but his hornblowers is negative. He's already tried therapy, cortisone, and all the usual stuff. Here's his x-rays, and pretty straightforward. Any concerns here? Ettore, do we have any concerns from an x-ray point of view? Looking at that, not really, because still there is some distance between the humerus and the cranium. Yeah. So far, so good, right? So I think everybody's gonna wanna see the MRI. So here's what we get on his MRI. Sarah, what are we gonna do now? Here's what we're looking at. Here's what we're stuck with. Got a little bit of muscle, heads up a little bit. His x-rays, his head was fine, right? Don't be fooled, because when you put him flat on a gantry on an MRI scanner, they lose gravity, but our x-rays were still pretty good. Yeah, I know this shows a massive cuff tear. There's significant fat atrophy, at least in the supra. This is probably someone who has, I would assume, an acute on chronic tear, where he had a chronic supra tear, and then when he fell or crashes to a bike, then it progressed on. Right, and that was six months ago still, so we have time. So in Canada, you're never getting an MRI in six months. What's gonna happen a year from now when you get the MRI? That's actually true, so next case, that's my problem. We'll present that one. All right, so here's his intraoperative video. We're gonna tell you, we went to surgery, and this is what we have when we're looking at, you know, we can do. So we're gonna kind of pull on it from all different directions, right? We're all aware that you've kinda gotta move it, see what you got. There's his biceps tendon, here's his cuff. Doesn't really wanna come out here laterally. Albert, where do we go? Well, so a couple factors here. He has elevation to 120, so he's not what I would consider pseudoparetic or pseudoparalytic, and he's pretty much an isolated supra, a little infra. This is a person I think I would try to repair as much as I could. I would use the biceps, actually. So I would save the biceps, swing it over, leave it attached distally, and then use that to augment a primary repair. So you're gonna take the biceps, so are you gonna just tenaduce the biceps in situ, or are you gonna take it out of the groove and pull it over to the top of the head like Larry Fields taught us, or what's your game plan there? Yeah, Larry Field technique. I'll release the sheath and move the biceps over to cover, because I think what's gonna happen here is that posteriorly you might have a little bit of deficiency, and try to get some marginal convergence there as well. So repair to the biceps. All right, so we've kinda heard about our options. Anybody wanna manage this guy non-op? I think we've kinda said we've gotta get to the operator and we've gotta fix him. So he's on set, and he comes back, and he says his lead actor on set told him he needs a stem cell shot. He doesn't need to have surgery so he can finish the show. Michael, any role for regenerative medicine in this case? I know we can't say stem cells today, but can we give him some type of medicinal signaling cell that's gonna fix him? Yeah, we get this a lot in Scottsdale. It's a very boutique little thing that's popping up when people are willing to pay, and people are willing to pay. So short answer is I just tell people that is helpful theoretically when we repair you. And then they say, okay, are you gonna do that? And I say, okay, fine, when we do the repair, if you want me to do a PRP injection, something like that. I think that maybe makes some sense, maybe some limited evidence in our world even that that helps. But as a solo treatment, of course not. No, that's not gonna be his treatment. Got it. So our options, we could go standard repair a la JK as he just told us. Certainly the tendon transfer, I think, has a lot of excitement. We just had the world's expert on SCR talking to us and augmentation options. And fortunately, we don't have a boot anymore, so we don't have to worry about the balloon here. But reverse, anybody gonna use a reverse in this 56-year-old laborer? No, that's universal no, and thank God because this is an arthroscopic conversation here. So what about interval slides? Dr. Murthy, do they have any role today with the techniques that we currently have? Or do you end up with just two little tiny pieces of unfixable tissue? I think you can do an anterior slide. I've never been a fan of the posterior slide. You can really divide a lot of muscle. And here, I'd also release the internal capsule, the superior capsule as well, to see how much mobilization you can get in that fact. But I wouldn't do the posterior slide. But I think anterior slide can get you some more motion, some more mobilization. Yeah, so I think the capsular release is really the important part, right? Making sure, as you heard earlier, be able to get that head down and so here's what we have. And so we got him mobilized. We've released the capsule inferiorly and start to bring it together. And to Dr. Kelly's point, this is what we were able to do. Is it good enough? Is this guy gonna be able to heal? Albert, do I need to do anything further or we can just leave at this point? So, I mean, if you're talking about sort of augmenting this with something, I feel uncomfortable with it only because you essentially have a single row of pair to essentially the medial side because that's what the tear could give you. So I think in these cases, I think there is a benefit of leaving the biceps if you have it. So now you have something kind of covering the footprint. And then I was just thinking about your marginal, your marginal or your interval slides question. There has been some papers written about that. It doesn't seem like those slides are actually beneficial for healing. And so, you know, in this case, I'm not sure I would augment that with really, with anything other than maybe a shot of PRP or something that's easy. So a panel, raise your hands if you're gonna augment. Who's gonna do anything beyond this case? So I'm gonna augment with his biceps, as you mentioned. I think it is worth noting because it is fairly new for us to be doing that in the US. I've been doing it for about two years now. My rate of Popeye deformity went up from about 1.5% in my cuffs with tenodesis to about eight or 9% when I do an anterior cable. So interestingly, my Popeye deformity rate is higher when I keep the biceps in continuity with the labrum. So you do an in situ repair anteriorly or are you gonna move it over like Dr. Fields? I do it in situ. I get the theory of trying to move it into the central part of the defect, but in my mind, the anterior superior part is the most important part of the rotator cuff, right? So I'm using it as an anterior cable rather than a biceps SCR. But I think there's really good evidence that helps your cuff heal. Are you tenodesing the distal part like subpec or are you just leaving the whole thing intact? Whole thing in continuity. And I wonder if that's what's, I'm getting almost like a Gile saw type of effect going through the biceps with my, the suture that's going around. So Dr. Snyder was basically tenodesing everybody like that. He didn't release a single one for the last like six or seven years of his career. And we actually didn't see that end up being a problem. So we tenodesed in situ a lot for these bigger tears. I think it's great. And so, you know, the real question in these cases is this quote re-tear rate, or I don't think it actually ever heals in the first place. I don't think it's necessarily a re-tear. And in this guy, we've got multifactorial risk factors for failure, right? It's a chronic tear. He's stiff with atrophic tissue. The blood supply is poor. We got poor biology. He's a smoker on top of all this. And so at the end of the day, I think the key is to counsel this patient appropriately that he's at a poor risk for poor healing no matter what. And if we look at the impact on smoking, you know, I actually had Blue Cross finally deny a surgery because the guy was still smoking. It was the best case ever. And I was like, ah, good. Sorry, come back when you're done. So can we really improve healing with biomechanical or biological augmentation? Dr. Ryu showed us a great talk on using the patch. Alan Barber and work that we did at SCOE showed that we can get double the healing rate if we use a dermal graft over the top in this case. So what I ended up doing was after I repaired the cuff, I ended up doing a dermal graft over the top with a dermal augmentation to be able to get this repaired. And to me, this, you know, had great value. We fixed his biceps underneath, and then we added dermal graft over the top. And I worry about these margin convergence repairs in terms of being able to get them to stay because I think when they see the failures of the margin convergence, they just kind of open right back up. And here's what he looks like both down below and above. We microfractured his tuberosity. I didn't add any external money. And he returned to work at eight months post-op, back to regular duty. He still needs some assistance pulling overhead cable, but he's back working. He's got no night pain. And at least for now, he's happy. So, so far, so good. And we're gonna talk about your case. So here's my indications at SCOE. Massive cuff tears, tears at risk, greater than one centimeter, chronic push traumatic. You know, if they have significant atrophy or guttale changes in poor biology. Ian, case two. Okay, so this is a six-year-old male, right hand dominant, right shoulder. He is retired. He's one of these mountain guys, likes to kayak, canoe. He does play guitar, so somewhat musical as well. December of 2021, he had a fall in ice. He now has night pain, waking pain, can't do sports. He's went through physiotherapy with minimal relief. He's otherwise healthy. There's nothing too much on history otherwise. He has physical examination is pretty unremarkable. Strength is four to five. He's about four minus of the five in external rotation, whatever that means. Plus five positive NEARs, atrophy of the infraspinatus. Here's his X-ray. Why don't we go from right to left? Sarah, what do you think? Does he have a lag, Ian? No, he does not have a lag. Yeah, X-ray is pretty unimpressive. There might be a subtle finding of some early OA, maybe a small spur at the inferior neck of the humerus there, but yeah, otherwise pretty unremarkable. Nothing too crazy. Mike, I don't know. I don't have every single view, but what do you think about this right now? This is the MRI. Pretty big tear retracted back to the joint line, the labrum, superiorly. Subscap looks pretty good. On the sagittals, that middle image on the bottom row, muscle quality is great in the supraspinatus, but not so great in the infraspinatus. And so he's probably got some effect of tethering of the suprascapular nerve at the spinal glenoid notch, because he's grade 0 in the supra and grade 1 to 2 in the infra. But that tear looks like it goes down at least halfway through, if not all the way through the infra. I think, to your point, he's pretty profoundly weak with ER, even though he doesn't have a lag. That's where I'm focusing my money. I'm going to do a primary repair for him for sure, whatever heroic repair I can get out of that. And if it's incomplete, then I'm adding a lower trap to that. Mike, do you think the muscle looks better, the supra, because it's retracted? Or do you think that's true muscle that's good? I think that's true muscle. I think volume-wise, retraction of a pennate muscle will change your interpretation of volume. But I don't think it changes the interpretation of fatty infiltration. So I focus more on the fatty infiltration. So are you going to get an EMG on this guy? No. So are you going to release his nerve? If it was suprascapular notch, yeah. I don't really know what to do with the nerve at the spinal glenoid notch. So no, I just pull the cuff out. And that's going to detether it from work that JP has shown us years ago. Would anybody entertain getting an EMG, no-conduction-velocity test? Hands up. No hands. All right, cool. How long would that take in Canada, getting an EMG? Actually, we have EMG guys who work in our clinic now. So it's only four months. Oh. Four months. Yeah. Four months. OK, so you're lucky here. Because that MRI was done, and we got to operate on this guy 18 months later. This is what he looks like now. So do you get a new MRI in? Are you able to do that? No. So because otherwise I'd wait another year. We can only get a new MRI if it's related to a study, and then we pay for it privately. So this is what he looks like now. He's 60. This is his. OK, Albert, what are you thinking here now? And you forgot to bring the kitchen sink. So I mean, this is an instance where you have pain and good function, actually, right? This guy's main complaint is pain, and he has some weakness. but one is I'm not sure you're gonna get a lot of weakness restoration with anything you do, one. So two is I think you can do anything on this guy and he would do pretty well, like if pain is his issue. And so I would do the simplest thing, which is to say you repair what you can, probably do a partial repair on top of this, unless you're convinced there's something that you can change the natural history of this, which I'm not either. I mean, you could put an SCR, you could do, you could put patchwork grafting, et cetera, but I'm not sure that changes the natural history of this. So if you were gonna address his main complaint, which is pain, I would just do debridement, partial cuff repair, and address his biceps. How about you, Anam, would you put a balloon in this? No, he still has good function, so he still has, I think it was like 120 in his past, so it was okay. So I'd do what Albert said, I'd repair the infer as much as I could and then bring the biceps just to answer to that for a cable. So let's just talk about the MRI thing for a second. So if you have an MRI that's 18 months old and we're gonna go back to the United States now, and what is your plan in terms of just saying, okay, I have this old MRI, we're gonna go to the operating room, I'm just gonna have everything in the world available, or do you repeat the MRI and what's the time interval? In America? Yeah, in America. I think we can definitely get a new MRI. If I don't have a new MRI within three to six months, I usually get a new one. Okay, so six months is kind of a routine. And how about in Milan, do you repeat the MRI or what's your plan? Pretty much the same. If it's more than six months or nine months, yes, definitely we repeat the MRI, but also we look at the clinical findings. If they're the same, probably we don't repeat. Yeah, because I think that's a big challenge, right? You know, you get in there, you peek and shriek, and you get into a situation where you may not have everything available. Does it change where you're gonna operate on this patient? Are you gonna move him from an ASC to a hospital? Are you gonna have to have different things available, especially some of these things that can cost a little bit more money? Yeah, for us, so when we are there, we basically consent the patient for almost everything except for reverse. I think that's a bit of a game changer. So, well, this is what we did. Tori, have you guys done any of this type of stuff where you try to resurface the humeral tuberosity or anything like that? So we tried to bring up the posterior cuff as much as we could, tried to do a little bit of a partial repair as much as we could. And then we essentially tried to do this resurfacing, intrapositional tuberoplasty. Honestly, I'm not really sure why I decided to do it in this particular case, other than the fellow wanted to try it. And so I said, okay, well, did you read about it? He's like, not really. And so we didn't really have a technique to use either. But I remember Kevin Bonner talking about it, and Rafi, so I said, okay, let's do it. And so this is one of our earlier ones. That's pretty good for on the fly already, measuring out. Well, we have everything available for us. So we have all the instruments. So in Canada, you can delay, but then you can do whatever you want when you get to it. Yeah, it's actually surprising. Yeah, we can put in dermal, we can put in collagen, we can do most things. We have a soft tissue bank and a bone bank always available for us if we need to do a DTA or whatever you need. How thick is that graft? Is that the thicker? It's a thicker one. It's not as thick as I would like, but that's the thicker one. Has anybody tried this technique before? What do you think? What are your early results, Anand? I think it works, just like Rafi said. It's like a spacer. It prevents some abrasions. So for pain, I think it's probably a good idea. He's shown that it's healed. It's probably what some of the failed SCRs look like. Probably the thicker, the better. Yeah, it's another spacer. What about you, Albert? You know, I've actually had surprisingly good experience with this, particularly in a patient like this that has good function. I mean, I don't think you, just like with anything, I don't think you could stretch the indication that it's somebody who has really, really poor motion, periodically. Yeah, we mentioned before. Oh, sorry, Sarah. Were you gonna say something? No, I was just, this is a patient I might consider a balloon on. I know the balloon's unpopular right now, but this is one, subscaps intact, still has over 90 degrees of flexion, so. Yeah, I thought somebody might choose a balloon here. What's your ideal indication for a balloon patient then, Sarah? Yeah, so someone who still has good range of motion. They have a massive irreparable-ish cuff tear, but they still have good motion and it's mainly a pain function. So, and they're subscaps intact. Yeah, I think the key feature is very little, if none of that was repairable, right? So if I'm walking and thinking I'm doing a repair and I can even get half of it back, I'm still gonna do that. But if all of a sudden it goes from, I was a planned repair and 10% is repairable, like very little, then I'm not sure what adding the repair does and then I just want some sort of tuberoplasty spacer type of effect and for me, that's a balloon. So if that's the case and you've got a five by five centimeter graft that you've opened up on the table, how do you decide when you're gonna do just a tuberoplasty versus an SCR and going to the glenoid? That cuff was medial to the glenoid. So how are you gonna make that decision for the audience to say, okay, this is the patient I'm gonna try to reattach that dermal graft to the glenoid versus I'm just gonna do a tuberoplasty? For me, actually, if I'm planning some sort of heroic soft tissue repair and it's not fully repairable, I'm actually doing a bridging graft as opposed to an SCR. Bridging into the cuff. Bridging into the cuff, your style, yeah. So I think that's easier and works maybe as well as the other options. So I don't use the tuberoplasty alone. For me, that's the spacer, that's the balloon patient for me, different patients. And Albert then, do you do SCR and tuberoplasty or how do you decide? I think for me, it depends on their pre-op motion. So we actually just published a paper in arthroscopy looking at pseudoparesis and comparing it to margin convergence versus SCR. SCR is actually, and this is an isolated supra issue, so SCR actually is a good indication in that cohort of patients. If they have good motion like this, I'm not really sure what an SCR confers. Alan, question? I just wanna put a couple of thoughts in there because this is my typical patient these days. So over the last few years, as Michael just mentioned, we started doing, probably about six years ago, we started doing in situ tenedesis and using as a jump graft, tie the supraspinatus to that and then get whatever we could posteriorly. So we just published on 50, the first 50, and they statistically were much better in terms of function, decreased pain. And then over the last two years, since we had the balloon, we've done almost 100 with, and in no case did we put a balloon in unless we could fix about 50% of the cuff. So we're using it completely in a different scenario where the goal is to protect the repair, prevent abrasion to the repair and to prevent scarring to the acromion, which in my practice, I do a lot of revisions and that's one of the, I would say, one of the top reasons for failure is someone does a decompression, they do a massive cuff repair, they put them in a balloon, they don't move for six weeks and the cuff heals to the tuberosity but it also heals to the acromion. Then when you start moving, it's just a question of which interface is stronger and a lot of them, they fail at the tuberosity, they heal to the acromion. So the balloon, in my essence, when I use it, I'm using it almost like a Band-Aid to my repair. And again, we're doing that study right now. $4,000 Band-Aid. It's a really nice Band-Aid. Yeah, yeah, yeah, it's a $4,000 Band-Aid. I know, but I found it really interesting. You can't get an MRI, but you can put in whatever you want when you're there, it's crazy. But look at all the money you're saving on MRIs. Oh, I get it. So good, so good. When you're doing the balloon, are you also doing a capsule release? No. No, just the balloon. I haven't been doing the capsule release unless they have an adhesive capsulitis. But the results have been very good. I mean, a lot of these are nasty revisions, third, fourth time in, and it's just interesting. The other thing is they have significant pain postoperatively because there is not that abrasion on the undersurface of the acromion. So we're studying it very carefully. It'd be interesting to see what comes out, but it's these type of patients that. So Ettore, very popular in Europe, right? The balloon is certainly started there and developed in Israel, started in Europe, and a lot of experience. I think LaFosse puts one in every one of his rotator cuff repairs as well. What's your experience? Maybe it was popular, but you cannot use the balloon in every patient. And I was laughing a little bit because I have a patient like this, like everybody, and depends where I operate on them, because in places I've worked in Switzerland, we have no problem with cost. And I use the SCR and I use the balloon. And I don't find any huge difference between the patients. I do just the partial repair, a patient with adding something. If the main thing is the history of the patient, you know, if they're acute on a chronic tear, if you fix it, maybe they go well, and that's it. So one more quick case. We've got three and a half minutes just to kind of run through. I think this is kind of interesting. So 74 year old male now, so we're a little bit older. He had a cycling accident in December of 2020, right in the midst of the pandemic. Came in and had immediate pain and weakness. At first, he was afraid to go to the doctor at all. He did home remedies, his pain persisted. He ended up sneaking into his primary care doctor who gave him anti-inflammatory, sent him to therapy, and he tried a cortisone shot. He had no improvement whatsoever. Still had pretty good range of motion, 150 of forward elevation, 140 of abduction. A little bit of weakness in abduction, external rotation, belly press and bear hug were both normal. And again, here's his x-rays. Not a lot of arthritis in this guy as well. So this is a 74 year old, super active, LA kind of guy, and here's his MRI, and this is in January of 2021. So we've got a year after his injury, and this is his cuff. So Sarah, what are we gonna do here? Yeah, no, I'm gonna fix this. Even 74, and I think we probably have a similar patient population up here in San Francisco. He's active, he's healthy, and I'm gonna give it a shot. I don't jump to a reverse, particularly in someone who doesn't have any arthritis or change. So anybody gonna do a reverse on this 74 year old with no arthritis and a repairable cuff? All right, so I offered him a rotator cuff repair then. He's like, you know, COVID's still kind of going on. I don't think I wanna have surgery. And so he went back to physical therapy and he did okay. His pain started to increase. He was playing tennis or pickleball, I don't remember which, and then developed more pain and came back now a year later. So now he's Canadian, and this is what happened to him. So now what do we do? Michael. Yeah, yeah, so his muscle quality is way different. That's a much more retracted tear. He's got some fatty infiltration now. His function now at this point is still what? He's, you know, he can get to 90, but he's unhappy. He just has pain now, he's miserable. And his subscap, I'm assuming- Subscap's fine. Looks good, yeah, his muscle quality's good. Yeah, bear hug, but belly press was normal. I don't know, I don't, my balloon patients have been very preserved range of motion. 90's pushing it for me, and I'm a big enthusiast for it, but that's pushing it. This might be a reverse for me. Yeah, Albert. Yeah, if he's really physiologically active, I'd have the convo. I think this is a person you could do an SCR actually on, and I think he would do okay, but if he just wants one and done, I might consider a reverse here. So, Sarah, you're gonna reverse now? I would still try to fix it. I'm kind of on the John Kelly plan. I think if you could try to fix it, I. As long as you're not on his meds, it's okay. All right, so, you know, we talked about all the things. He still says, he goes, I do not want a replacement. I am way too active. I play tennis. I don't want it. So I actually talked to him about dermal matrix options. You know, we talked about an augmenter bridge, an SCR. You know, I have a hard time getting that paid for and healed in somebody in their 70's, and so I really try to stay away from putting allograft in older individuals like that, and so, you know, what are you gonna do, and here's what we saw at the time of surgery. You know, cuff tissue looked decent, but I couldn't get it to move, and big hole, big defect, and we got stuck. So we only have 10 seconds left, so where's Dr. Abood when you need him? So I went ahead and blew him up, and we just put the balloon in. I did fix the anterior and posterior edges to kind of try to restore his force couples, as Father Kelly told us, and we put the balloon in, and, you know, really quick, really easy, and his x-rays still look fine. We did a limited smoothing, and pain's gone, and here he is at six weeks. You've kept the little ropes hidden really well. Hmm. So, which side, which side did we do? But, yeah, this guy was super happy, super active, and he's like, you know, I am not interested. You can see a little bit of his atrophy there on his right, but, you know, this was kind of right in the middle of COVID, and, you know, he's a happy guy, and so this was three years ago, and he's still doing just fine. So there we go, that's our balloon. Our indications are evolving, longer-term outcomes, and thank you all very much for your attention. Thank you.

rotator cuff tears

management

patient cases

surgical repair

augmentation techniques

reverse shoulder arthroplasty