Thank you very much, and thanks, John, for the invite. These are my disclosures. So not to sound like a broken record, but this is the problem, the massive rotator cuff tear. Chronic degenerative tissue, poor vascularity, it's retracted, scarified, a bad healing environment. A lot of these have previous surgeries, and certainly as I've aged and my practice's age and my patients have aged, I get more and more of these revision-type situations, older patients, tough problem, it's something that really presents a conundrum, as Steve said. A lot of times, in addition, there's just nothing to fix. So we have my colleagues here, five of the best surgeons on the planet, talking about this, and they're all talking about different aspects of this problem, and it's not that any one technique or aspect is better, but rather that we need to include all of these techniques in our armamentarium to deal with these patients, because you need to be able to alter your treatment paradigms in the OR based upon what the patient presents to you. So this panel is really about how to increase your ability to do that based upon the anatomy of the patient. So we've known for many, many years that it's possible to get these things together, but you need to spend the time to do so with debridement techniques to remove the fibrofatty tissue and interval slides to create excursions of the tendon units, and I think all of us, while we're talking about different aspects of this, would still agree, as Jeff Abrams did in the last panel, that to get these rotator cuffs repaired would be superior, right? If we can restore the normal anatomy, restore the muscle tendon unit, that would be superior to other techniques. The problem is you need to take time to do this. These things take time. You need to identify the tear pattern. It helps to look through multiple portals to do that. You need to do interval slides. You need to use margin convergence stitches and reduce the tear just as you would reduce a fracture, and then you need to get what needs to get down to bone to bone. The problem with that, and this is illustrated by this meta-analysis, or the systemic review rather by Henry in the Arthroscopy Journal, is that despite reasonable clinical results, ASES scores in the low 80s, pooled results, the pooled re-tear rate in these patients can be as high as 79%. That's unacceptable, but true. So what do we need to do? We need to change the biology, and there's a number of different ways to change the biology. You can change it with pneumodermal allografts. You can change it with biceps grafts, as Jeff talked about earlier. You can change it with biology like PRP or BMAC. There's some evidence that supports that in the literature. What about other inductive techniques? Well, this is a bio-inductive implant that I've been using for the last four years that has no inherent strength. It's made of highly purified bovine type 1 collagen, and it's meant to induce healing. The body sort of grows into this and makes a tendon-like tissue over the rotator cuff. And there's some good preclinical results in the sheep model that show that this is what actually occurs, that over a three- to six-month period, the tenoblasts grow into these things. It's a tendon-like tissue with vascularity, and that was reiterated in human biopsy studies also. We have some early clinical results with patient-reported outcomes and also MRI data that shows that tendon width can increase at least two millimeters with this device. And this is the result of a study that we did over the last few years, one-year results on our first 173 patients. If you look at the graph on the right, that's our full thickness group. This will be published in Arthroscopy next month. And it tracks a normal recovery of patients with rotator cuff repair. Interestingly, there were 10 patients in this group with massive tears. Their results were actually better than the overall group. Now, it wasn't statistically significant, but it represented a trend. And so this is the technique. This is a right shoulder lateral decubitus position. You can see a massive tear. A lot of work here has already been done. The gutters have been excavated. The fibrofatty tissue has been removed. We're coming in through the lateral portal and doing an interval slide. You need to take time to do this. We do a margin convergence and then a tendon-to-bone repair. And over top of that, through the lateral portal, we bring in the bioinductive graft, deploy it with a deployment device, and then it's fixed medially, anteriorly, and posteriorly with PLA staples and laterally with peak staples. So this is an interesting study that Buddy did, the group down in Tulane. This is a group of 26 patients, massive rotator cuff tears. And if you take a look at this early compelling study, this is a two-year result, MRI and patient-reported outcomes. And if you take a look here, this is for the large tendon tear group, large group, primary tendon repairs, 100% healing rate. Revision repair rate, 89%. For the massives, greater than five centimeters, 100% healing with primary repairs, 86% with revision repairs. That's some pretty compelling results. These are obviously early, and it's level four evidence. But this is something, this is very interesting, and I think it adds value to the healing environment of the massive rotator cuff. So in summary, I think we need to try to repair the tendon back to bone if we can. You need to reduce that tendon. You need to take the time to do it. You need to identify the tear patterns. And really don't short yourself on trying to repair these back to bone. Spend time. And I think at this point in time, we need to be thinking about changing the biology of the environment so that we can increase healing rate and hopefully overcome that pooled re-tear rate of 79%. Thank you very much.

rotator cuff tears

surgical repair

comprehensive approach

bio-inductive implants

re-tear rates