John, that was hilarious. OK, so next, my turn. Actually, Dr. Barkhart, I respect him, actually. He developed a very nice technique, partial repair. But actually, he switched to HCR before he retired. So maybe HCR is much better than rotocut repair. So my talk is short. Here's my disclosure. So massive rotator cuff tear has centennial and tendon defects. So even repairable, and after rotocut repair, weak fixation, high tension of the repair tendon, at the end, the high retail rate, we can see. And also, still, very high rate of retail rate is reported. But in my case, I do rotocut repair with HCR for repairable, but degenerative rotocut tear. And last 10 years, more than 300 cases, still 0% retail. So HCR can prevent retail after rotocut repair. So I really recommend this surgery. And next, irreparable cuff tear. So three biomechanical problems, irreparable rotator cuff tear has a large defect under the acromion, no tension in the shoulder cuffs, and lack of dynamic stability, and consequently, supermagulation of the femur head, we can see. So how to manage the three biomechanical big problem, large defect? Of course, period defects is a special effect, no tension. We need to make a casual continuity. It's a tension effect. And lack of dynamic stability, we need to improve force coupling. So partial repair, of course, we can feel the defect partially, but it's not completely, and no tension effect. And some partial, actually, partially, improve the force coupling, but not completely. So that's why Dr. Barkow switched to the HCR. And lower torpedoes, of course, the dynamic stability improved very well, but some still the defect, still there, and no tension effect, we cannot expect. But HCR using autograph fracture, it's not dermagraft, actually, autograph fracture rather. So we make a big graft, and we need to have a fracture rather, but actually, we can make a big graft, so that's why we can feel the defect completely. And also, we can cover the entire defect, so we can make a casual continuity. And also, dynamic stability, we can improve force coupling, because besides the suture between graft and posterior tendon, if the teres minor, the infraspective muscle quality is good, we can improve dynamic stability also. So I want to show some cases. It's a 51-year-old female, vulnerable player. Severe shoulder pain, and no therapeutic episode, and no paratreatment was not effective. And malational supra and infraspective chronic tear. Then, this is a physical finding. Active elevation, only 10 degree left shoulder is OK. And passive elevation, around 90 degree, very painful. And active external rotation, only 30 degree, and drop arm sign positive. So we did HCR using autograph fracture rather. Graft size, 3 centimeter by 5.5 centimeter, 8 millimeter thickness, inserted the graft into the joint now. And this is a final. Even 8 meter big, the graft, but you can see the space under the chromate means not only the space, it's a tension effect also. One year after surgery, active elevation increased to 180, and no shoulder pain, and returned to vulnerable. And MRI showed a good healing. And now, seven years already, but still good range of motion. And still, she's doing vulnerable now. You don't worry about the donor site morbidity. Actually, 49 female, vulnerable place. She has shoulder instability due to the atrial pneumatic iliparalotic tear, and she had dislocation. And after reduction of the dislocation, the narrow space we can see under the chromium. MRI shows a supra and infraspective chronic tear. Then, we did a HCR using autograph fracture rather, and no vascular lesion she has. This is the final view. Then, six months, still, but already active elevation 180, and no shoulder instability, and returned to vulnerable. Again, now she's doing the vulnerable at six months after surgery. Again, you don't worry about donor site morbidity. So this is a pause. So now, I can say, for sure, the HCR can make sure the greater care, right? Actually, HCR with LT-FASTA and subcutaneous DPA is the best combination. But if I need to choose one, HCR is good. We'll finish this outside.

HCR technique

Humerus Cuff Reconstruction

rotator cuff tears

autograft

biomechanical issues