to come on up, we have about 15 or 20 minutes to go over. Rick Angelo, Jeff Abrams, Rick Ryu, Joe Eichinger, Daniel Slittle, if you'll come on up to the podium, we're gonna talk a little bit about, I get to ask these guys some questions that are sometimes the things that you and I struggle with in the operating room, and Rick hasn't struggled since about 1985, so he can help us a lot, both Ricks, actually. Perfect. So the thought on this is just that we're gonna kind of race through these a little bit. We only have 20 minutes, and gosh, just between the two Ricks, I might get through a half a case, so we're gonna just get right to the punch and kind of go forward if we can here as well. And I've picked a few of these just to sort of demonstrate some principles. So, fellas, if you would just watch this video, what do we do with this one? So this is your first cuff tear. It's a double hold cuff tear. There it is medially. You look at that, it doesn't look very good, and you look out here laterally. Jeff Abrams. Is that, maybe, if Rick will share. Rick turned off all the other microphones, so he could be the only one to speak this afternoon, but. Does that work? Thank you. So here we are looking underneath. That's probably the most important, is to know where your tear is. If this is your anterior part of your cuff, probably involves the majority of your anterior cable, which is one of those more important stabilizing. The crescent area is less important. But I would assume that the articular view will show you that these tears almost connect, and that it's really a bursal surface that's keeping it looking like two separate tears. I would basically treat it as one larger tear. Jeff's so excited, he's lost his breath talking about this. Guy's so fired up, it's unbelievable. So, thank you, and I pick on Jeff a little bit, because he taught me this. So, when I was a young boy, and I would get into this case, and I would pull this open, and maybe you've had this happen to you as well, you look at this and you go, oh my God, how in the world am I gonna get, that's two layered tear, we're talking about SCR, tendon transfer, give up, bail, or whatever. But the important point is the one Jeff just talked us through, and that is, make sure you recognize your tear. Get to know your anatomy a little bit, because if you'll bring in a grasper set here, and you just take the time to see what the character of this tear is, and you look and you say, that looks terrible, and you simply pull on it, you realize, that may be the easiest cuff repair you do all year. So, while you sit and you think, my God, that's irreparable, and I don't know how many times maybe you've been there, but maybe I've been there, and you look at it and you just say, gosh, just take a few minutes to kinda get the character of that tear, and that simply becomes, just by understanding the shape that Steve and others have taught us about, this becomes eminently easy to fix, just as long as you know what you're looking at. So, we're gonna move into some cases today to talk about some of the controversies. So, here's the next one. So, Rick, here's a patient that comes into your office, has shoulder pain, if you will, 41 years old, scoped nine months prior, no MRI done pre-op, and operative report says that the cuff was pristine during the time of the operation. The patient never got better and comes to you in your office. How do we treat this? So, it looks like a fairly substantial intrasubstance tear. I think it'd be nice to see some other views to see how extensive this is. Sometimes this is fairly limited, fairly local, and if you scope this, sometimes that articular surface layer will be pretty flimsy, not very much there, and if you look at the bursal surface layer, again, pretty flimsy, depending, again, on the size, if the patient had had good conservative care, wasn't doing that well, I'd probably consider taking this down and doing a primary repair. Joe, active duty military, this guy, this is your practice for a long time. You're looking at this guy who comes in, can't do his PT test, is struggling a little bit. He sort of scores well on the Navy test, but can't pass the Army one. How do you handle this guy? Yeah, I agree with what Rick was saying. I hate to take down intact cuff, but sometimes you have to, especially if somebody's failed prior treatment. You know, what I may just try to do is just put one anchor in there and try to see if I can get that delamination out of there, but certainly, I think, in some cases, you do want to take down the intact cuff. I think if it's a bursal-sided predominant tear, that's much easier to do. The articular ones are a little bit more of a challenge. So are all of you taking something down here? Jeff, you shaking your head no. I think there's a, you could probably consider a graft. So, Rick Ryu, what are you gonna do with this? This is a case where you could consider a scaffold, and I think I've had some, at least in my experience, some good results on these intertendence tears in younger patients, and this- So when you're talking about scaffold, you're talking about putting something where? Inside the tear? On top of the tear? Bursal-side. Bursal-side. It has a zero strength, at no strength times zero, it's purely an ingrowth. It's kind of like tissue paper, and it's just a biological scaffold. And in these situations, in his age group, at 40-something, I think you can stimulate the biology, and you could probably do some trephonations as well, and go ahead and put that, just like you're doing there, yeah. So something that looks like that? Something that looks like that. Did you do that? Or did you borrow something else? I can neither confirm nor deny that question. So, Jeff, can you help me understand how putting a piece of dead bovine collagen on a bursal-side fixes an intratendinous, or even better, an articular-sided tear? One of the famous folks in the audience once said that if you're gonna accept that concept, you have to suspend your disbelief, which I always thought was pretty clever. So I do have a conflict with this company, certainly during the designing period when this was probably done. That being said, I think there's really two theories on why this can work. First of all, cutting out tissue and making the smaller tear into a bigger tear, I don't know how you feel like you're gonna win that battle. Because you're still asking for biology, there's tension issues, you're almost always gonna lateralize your tissue. So you're always gonna save cuff if you can save cuff. Yeah, I don't think there's such a thing as bad cuff. I'm willing to sacrifice and deal with bad cuff a different way. So an onlay graft will do one of two things. It'll add two to three millimeters of tissue on the bursal side. If you mechanically thicken, whether it's the replacement, the scar tissue, whatever you wanna call, it will unload what's going on underneath it. That's one theory. The other theory from Steve Arnosky is a one wound issue that just because you put it on one side of the tendon doesn't mean there's not biological activity throughout the thickness of the tendon. These are almost, that impressive picture almost always occurs with a post-operative failure. You rarely see those as primary cases. So that already has been through an attempt at tuberosity fixation and has not been successful. Well, actually, he didn't put any fixation in. But the truth of the matter is I've had a number of these as post-operative looking MRIs and then did the onlay graft to it. Daniel, help us bring some sanity to this group, would you please? So what would be your approach and is there a role for biologics or is this a full takedown in your hands? What would you do with this? Sorry, but I would like to point something. We got to have good care with the bicep tendon. Because if you've got that type of intertendinous issue, the tear will go anterior and could burden the first part of the stabilization of the bicep tendon. Okay, so a pulley lesion then in combination with this? Yes. Okay, so does that mean that this care gets a biceps tenodesis or tenotomy in your hands? Yes, for me it's very important. Is that all or do you do more? No, I do, of course, I would take down the partial repair. I do a total repair and I do a tenodesis. Makes sense. Any role for biologics here, PRP on the panel? Let's start with PRP. In terms of getting it to heal? Yeah, maybe just treat this as an injection. I'm unaware of that data. You know, I will tell you the one thing you have to consider is that the implant that you put in has peak anchors in the tuberosity and you have to consider whether or not stimulating the tuberosity may somehow also generate a healing response if this indeed was helpful. So would you consider Steve Snyder's crimson duvet and trephinate around that in addition to a scope? Is that a reasonable approach? I know that Mark Gettleman and probably Steve are the same thing that in a case like that you just go through instead of trephinating you actually go in and microfracture the footprint through the intertendons portion in hopes that it fills in. So yes, there are things that can be done beyond what we just chatted about. Interesting, there's a number of biologic additives that are out there now. This is an umbilical cord strip that's going in there. There's PRP, BMSCs, et cetera. And interesting that our panel is, nobody's really jumping on this biologics train too fast. So maybe you're waiting on the science. Are there any cells in that umbilical cord material? Yeah, it's interesting. There are not cells in that. But then there's a real controversy as to whether it's the cells that matter. There's exosomes that people think are important and it's the growth factors themselves that may attract the satellite cell that comes in that actually plays the main role here. So there may be stuff on the future, but I think our panel is pretty wise in sort of helping us to stay away from that. Let me move on to another one. This one's one that I think strikes fear in the hearts of all of us. So this is one of my patients. He's 60 years old. He and his brother-in-law get into a Super Bowl party. One of them's a big Patriots fan and his brother whoops his ass as he should. And so he has a two-month history of pain and weakness. And I think it projects pretty well on the screen, but this is a fairly medial tear. So Joe. Yeah, that gives me certainly some anxiety. I think that I'd really wanna look at the muscle laterally and see what that looked like. I think in a two-dimensional view like this, as you showed in the previous case, sometimes if this is an L-shaped and maybe the tendon has moved either anterior or posteriorly it might not be as bad as you think. But certainly it looks like there's a little tendon left on the greater tuberosity which would certainly make me concerned. And I would probably lay some crepe with the patient. I don't see a lot of arthritis and much like Dr. Burkhart talked about, I wouldn't wanna move to a reverse on this person. I think I would still try to do a repair of this. I think there's value even in a partial repair. The question is whether or not if it's gonna hold up. So you wouldn't give up the ghost chest yet. We'd take a look. Rick, were you? This is eminently fixable. Eminently fixable? It is absolutely positively fixable. A cute tear like this is gonna be close to the musculotendinous junction. Don't you hate that when you show one you can't fix and he says it's eminently fixable? Yeah. You know that you're about to just wet your pants in front of God and everybody? Thanks, Rick. You can do a fancy stitching pattern to bring tendon to tendon and it'll come over acutely. So you'll fix it tendon to tendon. Tendon to tendon. That's what you mean by eminently fixable. Yes, and then we're gonna augment it. So we'll go ahead and put a patch on top of it. You're gonna put another one of those bovine collagen patches on the top. No, we're gonna put an acelodermal matrix. So this will be a true augmentation and all the studies show that this is sort of ideal. You look at the study by Larry Higgins. It's probably the only one looking at this type of injury and the results were actually quite good but there wasn't a lot of imaging. We have a series of about 16 or 17 that we've done. Half have been done with the augmentation. We had two failures in our first seven without augmentation and the last nine or 10, no failures. So this is definitely fixable because it's acute and that retraction makes it look much worse than it is but it'll come out, there'll be very little tension. It's really tendon to tendon healing you worry about. So the augmentation takes care of that. Jeff, you were gonna add to this please. So you decide whether this was winning the fight or the guy losing the fight. If he's winning the fight, he gets the Santa Barbara treatment of the expensive graft but if he's the loser, then I would have used his biceps tendon and put an anchor anteriorly and then went across the suture line with the biceps tendon and actually created the second layer of collagen with his own biceps. So you're bringing it underneath whatever you can repair or are you taking it 90 degrees and laying it across to create a little bit of a buffer there? I would take it out of the shoulder through the rotator interval around the anterior edge of the supraspinatus and on top. So it would become a Steven Burkhardt cable but it would be on the bursal side rather than the articular side. Understood. Daniel. Nothing more except I don't want to operate on images. I want to operate on patients. So let's see and do what we can do. Makes sense. So you're right. I think that this was an interesting one for me. We went in there and I think that we did not elect to do Rick's option except that you can see this is an example of look at the two stitches that we have preplaced. So just as Rick recommended, we did an SCR on this patient but we went ahead and repaired the cuff over top. Again, not under tension but bring the cuff out as far laterally on the patch as possible so that whatever fires that's left will kind of get us kind of in that position in that regard. So one option to do this. Jeff, you mentioned that you would do biceps tendons in these regards so you would bring the biceps but you would bring it out laterally over the top. Do you then separate? Do you do a tenotomy below this? Do you tenodesit in situ? Or do you take it off the glenoid side? In this case, I would take it off of the glenoid, out the rotator interval and have about two to three centimeters of tendon to work with on top of the supraspinatus runching and actually having the distal insertion into the infraspinatus. And then do you take it out of the groove to get to eliminate that or you just ignore that part? No, because it's tenodesit to the anterior anchor. So it would be as if it's a standard tenodesis above the groove. And so I don't think you have to take it out of the groove or do anything below it. If there was very diseased tendon, however, then you could argue to do a suprapectral tenodesis and then cut it above the suprapectral tenodesis and then bring the distal end up on top and leave the edge attached to the labrum anteriorly. Joe, just a quick question. So what if this guy is 60 and has terrible muscle, so guttaliate three and four? Does your approach change and is there any role for a reverse in this guy? I think there is still a role for reverse. I usually give the patients an option and I've been doing tendon transfers for these. I haven't gone wholesale to doing the SCR, but this looks masterful, you've done. I think, you know, depending on their exam as well, I mean, if they're really weak or pseudo-paralytic, I think that's a tough road to go for an SCR. And so I've leaned more towards either doing reverse or a tendon transfer. Perfect. I think with that, guys, in order to stay on time, I think I'd like to thank the panelists and thank you guys for being a part of it. Thanks very much. Thank you.

cuff tears

treatment options

shoulder

tear identification

biologics