All right, so we get a little bit of an interactive session and we thought maybe what we do is present a couple of cases. These are my cases and Jeff can help me be a better surgeon and I think certainly can help us all, so certainly a master for the shoulder. So this is one of our cases, this is a 52-year-old, he's a reservist in the Air Force, a mechanic, now unable to work acutely after an injury five months ago when he was working overhead. He comes in with pseudoparalysis, forward elevation of 60 degrees, abduction of 45 degrees. He is full passive motion, an intact subscap and you can see there from his imaging a large massive rotator cuff tear with grade four atrophy and in the scope picture there looking in this left shoulder, degenerative appearing and poor quality rotator cuff tissue. And so Jeff, my first question to you is when you're encountering these large massive rotator cuff tears, we have a variety of different options. Who's getting a partial repair? Who's getting a reverse? Who's getting a tendon transfer? Who's getting an SCR? How do you make up your mind there? The first thing is I think everyone that you're considering is to go for a full rotator cuff repair. All of the other options you presented are less advantageous than fixing the tendon that's there. Then the question really comes down to if you fix it, will it heal? I think you, with a five month history, that range of motion, active 60, I usually, if they have full passive motion, bring their arm overhead, usually let them use their other arm if they could hold it over their head independently of their other arm. They have enough strength to come back and get this done. There's not much atrophy noted on the shoulder, 52, so I would be, none of the choices there are fix the tear. I would fix the tear. If you don't get it completely repaired, then I'd do a partial repair and I'd use the long head of the biceps to fill in the defect. But I try to go with an index procedure as an all natural repair. To answer the rest of your question, the reverse is for more arthritic shoulders, generally in an older patient. Tendon transfer is becoming less and less useful as we get better with the superior capsular graft, but that would be a person who has, needs the active movement, particularly external rotation. If external rotation was critical to this individual, I'd be considering the tendon transfer. And a superior capsular graft is when you really don't have a chance fixing this. And this is often, for me, revision or a case where you just can't get the tendon anywhere near the tuberosity and you think it's a lost cause. And I think you mentioned some of those with regards to the biceps. How do you, can you describe that a little bit? How do you, how do you maximize those? What kind of tips do you have for using that biceps as a graft? So the biceps, first of all, if your subscap is not good, do that at the initial part of the case. If you get your subscap back, then it will help you reduce the leading edge of the supraspinatus. For the biceps, I usually will tag it with an articular stitch, release it from the labrum and bring it out the rotator interval, which is medial to the comma sign that Steve has proposed. And then I'd get up on top and put an anchor just along the leading edge of the supraspinatus, combine mattress and simple sutures, medialize the supraspinatus repair. And then after I'm done putting a poster anchor in, bring the biceps over the top and secure the rotator cuff with like a transverse band of collagen, which is my biceps tendon, creating like a luggage strap across the top of that. So I have a double layer repair, which also helps with my acromial-umeral distancing. So we were able to mobilize his infraspinatus over, repair that. His supraspinatus, even with some release, unable to mobilize that. We did an upper border of the subscap repair. And then, so this is just kind of our process here. And then the converging sutures anteriorly and posteriorly. What do you do with the remnant of the rotator cuff that's there? We had just heard a technique for augmenting our grafts with that. Do you try to do that in every case? And how do you manage that? Yeah, we're always focused just on tendons. And we're trying to do a tendon repair. But the real action is the muscle that attaches to the tendon. So don't give up on anything. If you can't get your muscle out to the tuberosity, then sew it into your repair immediately. So I'll sometimes go across with the biceps tendon and actually sew my supraspinatus into my biceps tendon and use the tendon as like a tendon graft or like a hair extension. And so don't give up and leave muscle that's not attached to the shoulder. If you can incorporate it into your repair, incorporate it. All right, we thought we might get one instability case in here for you. So this is a 24-year-old. He's in the Honor Guard back home in D.C. He's also a combatives champion. He's unable to perform his duties. He's normally a 80 push-ups in two minutes kind of guy on his PT test. He's gone down to about 30 in two minutes. We saw a picture of this from Dr. Bradley with his kind of voluntary jerk, so to speak. His x-rays there showing maybe a little bit of subtle bone loss posteriorly. And these are his imaging there with a little bit of a posterior humeral head station. His scope looking from anterior in the lateral decubitus position. You can see there the posterior labral tear and that bone that's posteriorly a little bit of a bone loss situation. What for these and kind of working in the dark side of the shoulder, maybe where some of us are not as comfortable and don't see this as much, what do you have or what are your tips to get the posterior stabilization right for these patients? So looks like you put the anchor on the defect, which is number one. So scope is anteriorly looking posteriorly, mobilize your labrum, and then basically put your anchors on the articular surface to basically cover up the articular defect, the GLAD lesion. If you leave the GLAD lesion exposed, even if you stabilize the shoulder, they'll still have pain with 90 degrees of forward flexion. So you want to put a biological cover over the top. Second thing I would have done probably is mattress sutures that take the soft tissue and pull it up on the top. Not only does it tension it, but it'll also bring it forward. The third thing would be in cases where it's revision or poor capsular tissue, I will sometimes take the sutures that not only grab the capsule, but actually pull it through the infraspinatus, similar to what you do, REMP massaging on the opposite side of the shoulder, and actually sew it on the external of the infraspinatus. And last, I keep them in a sling for about six weeks, at which time they start supine forward flexion. You want to get their scapula. If you would stand behind this individual and push on their scapula, he would not be able to send his shoulder out the back. So if his scapular muscles become more appropriate, it's almost a proprioceptive issue in this individual, he's not aware he's doing it. We blame the winging scapula because of the subluxation. In reality, it invites the subluxation by rotating the base of the joint. So if you could get him to retrain his scapula, so day one, even when he's in a sling, he's doing scapular stabilizing exercises. And when you want to reintroduce him to forward flexion, start him supine because the table will act like a support behind it, and then get him upright afterwards. Make sure you have some scapular control before you get him back. He'll have a relatively uneventful recovery. Keep him doing 80 push-ups, he'll probably stay strong. And what about, you know, we've heard JT and Dr. Bradley mention this concept that maybe there's some posterior bone loss in JT's study. About a little over two-thirds had some measurable bone loss, and about 20 or so, 22%, had over 13 and a half percent. Didn't change outcomes, as we know, but is there an algorithm where you start to think about this, or you worry about it, or is it not an issue in the majority of your cases? I've done a fair amount of posteriors, I have not done a bone graft. I think the hard thing about anterior versus posterior, anterior you can place the bone graft a little bit medially. The problem with posterior bone grafts is understanding the retroversion of the glenoid, and not interrupting that arc of circle with your bone posteriorly. So no matter what I did, if I did consider, and I would say the numbers of 25% arbitrarily should be a thought process, I'm thinking more that if your soft tissue is totally inadequate, then you need to put something back there to help you. If your soft tissue is still good, I don't know what the number is for the bone loss that becomes a critical issue. But if you have no capsule and labrum to put up to it, then you're really looking at a difficult situation. Understand preoperatively what you think is the radius of curvature of a bone. Because more than likely, if you look at postoperative x-rays, first of all, they're on dysplasia glenoids. That's a whole different animal, and I don't think you get it right because of that thick labrum that normally exists there. If you put it in and it interrupts that arc of curvature, everyone's worried about the step off of the articular surface to your graft. Both anteriorly and posteriorly, arthritis comes because of the most lateral aspect of your graft not matching the radius of curvature. That's where the hardware complications come in as well. So you have to match radius of curvature when you're grafting anteriorly and posteriorly. I think it's a pretty difficult thing, but I would only consider that when there's no soft tissue to use. And as an infraspinatus capsule combination, I will do a REM plissage on the medial aspect of the joint rather than the typical lateral point to try to bring the soft tissue up to the glenoid and go with that as my first choice before I use a bone graft. That's great. All right. Well, in the interest of time, I think we'll turn it back over to our moderators. Thanks, John.

rotator cuff tear

tendon transfer

posterior shoulder instability

anchors

articular defect