Thank you. We started working with ACR in 2014 when Miyata published his excellent clinical results. And because we need an option for the relative young and active patients with irreparable rotator cuff tears, this is my disclosure. Why? Because it's a well-defined and constant anatomical structure. If you see, this is a personal dissection, the video of the left. You can see the infra going medial behind the scapular spine and how the superior capsular goes to the glenoid. It's the principal primary structure of the superior hemorrhagic head displacement. You have a very nice biomechanical study that proved that, and you can see in the post-op how the hemorrhagic head goes down when you finish your surgery. The published clinical results are very encouraging. We have a lot of papers published with a very high level of evidence that prove this. And it's an all-ultrascopic procedure with less incidents and, as Steve Burke had said, magnitude of complications. When in massive irreparable rotator cuff tears, I can use it with or without patient's cerebral paralysis, good or repairable subscapular and functional deltoid, minimal degenerative changes in glenohumeral joint, usually hemorrhagic grade 1, 2, and even 3 with our technique, and in relative young and active patients. How MIATA shows the technique with fascia lata quadruple or triple. I think that you have a lot of morbidity there, especially in the donor side, and some technical difficulties. A video from MIATA is a very big graph, and I think that it's difficult to get inside the subacromial space, this graph with suturing sites. Quadriflex is an excellent graph, strength and no morbidity, but the problem in Latin America and a lot of countries in Europe is we don't have availability for regulatory issues. So we start working with fascia lata, simple or double. We harvest in a safe manner from a very small incision over the trochanter, and if you use double, the thickness of the graph is between 6 to 8 millimeters, and we add two fiber tapes, one anterior and one posterior as an internal brace, and a lateral tape in a mattress configuration for the glenoid fixation. We add an extra cinch stitch for the 12 o'clock anchor to have three anchors in the glenoid. We use a knotless configuration in the glenoid and in the humerus side. This is a revision case. We prepare both sides, glenoid and humerus side, trying to have a good bone bed for the graph. Usually we work in a beach chair position. We try to have a bleeding surface. First of all, we made glenoid holes, three holes, one anterior, one posterior, and a 12 o'clock hole. And then we measure the gap and prepare the graph. This is the 12 o'clock. We try to put the holes down anterior to prevent the anti-superior scape of the humeral head. Then we push the graph inside without sutures and pull from medial, from anterior and posterior, and fix in the glenoid side with a knotless configuration, 3.5 biocomposite screws, anterior, posterior, and a 12 o'clock. And then we finish the surgery with a transosus equivalent in the humeral side. This is the final product. We try to do capsular continuity to the infraspinatus, and this is what you see at the final step. In the last year, we are using mesh, trying to have less morbidity. We are using fasciae latae simple or double. It depends on the thickness of the fasciae latae. This mesh is a polypropylene mesh. It's very elastic, as you see, and it's easy to work with this type of graph inside the subacromial space. We fix it at the glenoid with a knotless configuration, mattress, and a transosus equivalent at the humeral side. Less strain, better restriction to superior translation, and no restriction to normal rotation, as you see in the cadaver lab. Final thoughts. Joint preservation, chondroprotection, the same thing we are doing in hip, knee, and other joints. I like to think in this concept of biological reverse, decrease the need of reverse. I think that we have to have reproducible techniques and to have a reverse trampoline effect at the final product. Thinking SCR, I think it's very important. The most important thing is that the results have good indications. Thank you very much.

arthroscopic cuff repair

irreparable rotator cuff tears

ACR technique

clinical results

graft options