Thank you. I want to thank Dr. Kelly and the entire program committee for the opportunity. And I think he put me first because half the people would be out of the room still as we talk about partial repair here. So my disclosures are available at the program and the AOS website. I think if we talk about case-based, it gives us a sense of what we're talking about. If we have a 71-year-old active individual who's an avid swimmer, I see this patient all day long in Los Angeles. Vague shoulder pain for years, prior tennis accident, no response to therapy and NSAIDs, has good motion, a little pseudoparetic, marked weakness with forward elevation and external rotation, x-rays, HMADA 2, and our MRI shows a little bit of moderate atrophy, maybe gutality A3 even, with some proximal migration. And the problem there is how are we going to deal with this potentially high re-tear rate after a rotator cuff repair with two-tendon involvement? And I think the real question is, is it a re-tear or just never healing in the first place and how are we going to address this? I think there's multifactorial risk factors that we have to deal with, chronicity, the stiff atrophic tissue that has limited blood supply, poor biology, and in an older patient, we're basically dealing with poor healing. And so how are we going to handle it? Joe Iannotti has told us that the vast majority of these patients end up re-tearing early on and so it's important to get your repair strength, your tension, and improve blood supply as much as possible. When we look at small versus large tears, there's a very big difference in that larger tears have fewer fibroblasts, poor blood vessels, and inflammatory cells, and they undergo this large tear metaplasia that makes it way more challenging to get these people healed. The smaller tears are more likely to heal, but in this case we have a large chronic tear with two tendons in an older active individual. And so how are we going to go ahead and manage this big tear without putting too much tension on this as we try to bring it over so we can't get it all the way out to that lateral edge? So what is the role for partial repair? I think most can actually be repaired if you think about it, at least to the medial edge of the footprint. You need to do articular and bursal-sided releases and consider interval slides as well. Dr. Burkhart many years ago in 1994 talked to us about the earliest phases of arthroscopic assessment and repair and what we understood with the partial repair, particularly back then, was we had to recreate a balanced repair. We had to restore the force couples and create a, quote, functional rotator cuff using the suspension bridge concept that I still think holds value today. Many years later, Oh looked at this and provided biomechanical support as well, but we have to restore the posterior rotator cuff to improve the glenohumeral kinematics. And interestingly, this is often reported as important for the SCR that you're going to hear about later this morning as well. So the basic principles for partial rotator cuff repair are repair the subscapularis, get maximal mobilization of the supraninfraspinatus, do capsular releases on both the articular and bursal sides, and release the corcohumeral ligament. I think interval slides have value and Dr. Burkhart's going to talk more about this. And there are some questions about low tension partial repair versus an aggressive release group. If we look at Steve Weber's work, when he looked at 80 patients that he did partial repairs on, he did no interval slides or heroic techniques and had 88% good to excellent results with improved external rotation strength, no proximal migration or progression of atrophy. Porcellini and Castagna looked at this similarly, and from 67 cases had improved outcomes and improved patient satisfactions. When we looked at what Larry Field and Buddy Savoie have also shown us, when they did a comparison of partial versus complete repair, they both had excellent outcomes and no statistical difference. So what do we do? Is that enough? So we'll go ahead and do a partial repair in this case. We'll start with some margin convergence, and we can mostly get this tendon back to bone, just to the edge of the footprint, and we can start working on that. So is that good enough? I did restore this functional rotator cuff, but the real question in my mind is, will it heal? So partial repair, I think the evidence-based medicine supports its role. Several studies have shown improved outcomes and less pain, and the risks and complications are very small. We don't burn any bridges, but the question really is, does it hold up? If we look at Shone's work, looking at 31 patients with greater than five-year outcomes, the results deteriorated with time, and 50% of them were not satisfied long-term with increased pain, increased narrowing of the acromial-humeral distance, and if you had fatty infiltration, it's going to be a problem. So if Kelly asks a SCOE guy to talk about rotator cuff, I can't really keep my mouth shut and just talk about partial repair. And so the real question in my mind is, why wouldn't I add a graft? We've pioneered the use of dermal allograft for this, and the evidence-based medicine can support it, but why not add a graft on top of it? Can we improve outcomes and healing with biomechanical adjuvantation? I think the answer is yes, and I think dermal matrix allograft is something that may be beneficial. So in patients who are having revision repairs, a massive tear like this, or a tear at risk which has some significant atrophy, I would add that, and the biomechanics tend to support that as well, looking at improved strength of our repair, and when we look at a level two clinical study, you got double the healing rate by adding dermal matrix allograft over the top. So in my hands, I would do the partial repair, but then I would also most likely add a dermal matrix allograft over the top of that to try to get improved, secure fixation. So I think there is a role there. So in conclusion, partial repair does have benefit. Today, in my mind, it's unclear whether to do a partial rotator cuff repair alone or to add a graft. Whichever technique is used, we don't burn any bridges, and I think it's a very viable option for a very difficult group. Thank you very much.

partial repair

rotator cuff tear

older patients

force couples

dermal matrix allograft