Bring up Dr. Toro's slides, please. Thanks very much, John. And thanks very much to Anna and Issacos for inviting me and having this great meeting. So yeah, I'm going to talk to you about why you should fix the tear in most cases. And I think everyone in this room who does a lot of rotator cuff surgery sees a ton of partial thickness rotator cuff tears. And you're always wondering, what's the best thing to do in this case? Here's my disclosures. So let me just start out. I give up. I give up. I'm giving it up to Rick. You look at this case, and it's a very partial thickness rotator cuff tear, maybe let's just call it 25%. Debridement has never worked well in these cases. And I'm sorry these slides aren't projecting the way they were designed. But that bottom line says biologic augmentation is, I think, just fine for this type of a case that we're seeing here today. Usually, we'll see when it isn't. And I give up again. I know everybody's disappointed that I'm not up here arguing, but I want to give it up to Guillermo. Let me tell you, I have a patient who's the perfect example of what not to do in my office right now, a 38-year-old. He had a failed cuff debridement. He had a failed bovine collagen patch. He's got full range of motion and strength. He's got a negative. He's got no lateral deltoid pain, no impingement signs at all. And all he's got is anterior shoulder pain. So this guy needs a biceps operation. If the biceps is tender and you don't have cuff signs, then fix the biceps. Or if you do have cuff signs and you have anterior tenderness, fix the biceps. You don't want to just leave that alone. But what about this patient? So this is a 45-year-old patient, 85% passive range, no anterior biceps pain, 4 and 5 supraspinatus. Otherwise, everything else is normal, has impingement tests. And I would say that this is about, what, 75% thickness avulsion, pretty big tuberosity avulsion from the underside. So let me show you guys what to do with this. The first thing is you need to know what's going on on the bursal side with this tendon. So you have to mark this tendon with a PDS and then go look at this on the bursal side so you see the quality of the tendon. Now, this case, I'm palpating this tendon. It's in good shape. I can't poke through it with my probe. I don't feel a big defect. And I know someone's going to argue, well, look at the histology of the remaining tendon. Well, look at the histology of a repaired rotator cuff. If I think I've got good collagen there, I'm not going to take it out, as opposed to this case. So this is another case where I'm taking my probe. Wow, I can feel a big hole, and I'm just going to poke my nerve hook right through that tendon. And that's one that's not good enough collagen to leave, and I'll take that down. But the repair is the same, no matter which way you do it. You want to do minimal damage to remaining tendon and don't over-constrain the repair. And so number one, if I'm going to go through the remaining tendon, I'm going to use a very small anchor. This is actually a 1.8 anchor that I actually put in through a 1.3 cannula. And there's just all these percutaneous kits that can do minimal damage to the remaining tendon that are on the market from various suppliers. And then the other critical part is, I'm just using a spinal needle to go through the remaining cuff to pull it down. And if you looked where I put that, it's just at the capsular margin. I'm not trying to over-constrain this repair, because you will make them stiff if you go too medial with your sutures. And then I'm just going to tie those two anchors over the top, and here's the other thing. It doesn't make any sense to me to repair a pasta lesion back as a pasta lesion. So these will get double-rowed for the most part, and there's my completed repair. So what about the old collagen patch magical thing? So this 50-year-old patient is a patient of mine that I did a bovine collagen patch on. She developed severe post-operative stiffness, really full-blown adhesive capsulitis. So as you can see on those slides there, there's a lot of blue stuff floating around over the top, and I did a full capsular release. And here's the real problem. If you look at that MRI scan on the left, that's her pre-op MRI. Her post-op MRI is worse. So I actually wound up doing a cuff repair on her. So that's what you're supposed to do. Thanks. APPLAUSE

rotator cuff tears

biologic augmentation

tendon quality assessment

repair techniques

collagen patch complications