Thank you, Dr. St. Pierre. We have just a few minutes for questions. If anyone has any questions, please step forward to the microphones. While people are coming up, I just have one question for our panelists. Obviously we've talked about the options for a primary massive rotator cuff repair. Do you guys have any tips or techniques for the revisions in these young patients after you've tried to repair a massive rotator cuff or a partial cuff tear? Obviously you're dealing with some bone cystic from the prior anchors. Any tips or techniques for those revision cases? Dr. Gittleman, I'm going to put you on the spot for Dr. McIntyre. We get the mic. Sorry. Yeah, so that younger patient with the massive, obviously we're going to try exceptionally hard to try to get that rotator cuff repaired. A lot of times you can do that. Luckily, in the younger patient, the bone quality is pretty good. So in my hands, for that younger patient, especially the patient in the 50s, the late 40s, massive tear, maybe a couple of revision surgeries, as long as there's subscaps intact, then that's my indication for an SCR. Make sure you put the SCR in. Make sure you repair it. I put the repair both anteriorly and posteriorly so you get that trampoline type effect, but that would be my trick for that. How about if you've got cystic formation in the humerus, how do you deal with those type of revisions, even in the setting if you know you're going to do an SCR? So one point is if you have cystic changes, it really depends where they are. If they're big, some of them are just absorbable anchors that are going through the absorbing process, I'll try to ignore those and come medial or lateral to those areas where I have good bone quality. If I am concerned, I'll bone graft those areas or I'll do a stacked screws technique as Dr. Burkhart showed. It always is a real estate issue in revision. Sometimes you're dealing with multiple anchor placement sites and that is always an issue, but usually you can find some type of area to get the anchors into. Bone grafting, I've done that. Stacking, done that also. One more thing you can use. There are several companies that have these osteofil type of products that you can use to fill in bone. And then also if you're doing an SCR, just take your anchor down laterally a little bit further so you get the good hard cortical bone and they can hold those lateral anchors. I would also add too that on those revision cases, I'm not, I typically check for P-acnes before I go. I've caught a couple where they were infected and looked fine and had to treat those people. And then once I got them cleaned up, came back and I've used interference screws, eight, nine millimeter screws sometimes to go where I needed to go. And particularly that case that Dr. Burkhart showed, that was a win, but could have been a loss with very soft bone there. So sometimes I'll use interference screws with mulberry knots and then you've got another suture there that you can utilize in extreme cases. Perfect. Thank you. We have one question from the audience. Yes, just regarding the reverse total shoulder, are you using? We couldn't hear. I heard subscapularis, so I'm guessing that do I repair the subscapularis? Correct. Yes, correct. And yes I do. There are some people that are proponents of not doing the subscapularis repair and the thing is that what I think I get is a better result. Obviously, in fact, some of those patients did not have a subscap and the reverse works well. They don't tether it, I repair it anatomically, they get all the range of motion back, but I think those are the guys that are lifting weights, doing pushups and doing all that kind of other kind of stuff. I think the subscap is still very valuable even with a reverse. How are you fixing the subscap? For reverse, I'll do drill holes and I'll put suture into the tendon and I do a double type of technique, but it's kind of a suture bridge technique. I use suture tape that comes from the implant through the bone and then I tie it down and also tie it to soft tissue as well. No I think that's a great question. The question was do I immobilize them for six weeks to allow that tendon to heal, but if you think about it, when you do an anatomic shoulder replacement, it's a non-constrained system, so there's a lot of stress on the subscapularis when you're doing the rehab. If in a reverse, you have a constrained system, so it doesn't have that same mobility, so I think the subscap probably heals better. I immobilize them for four weeks and I have them do their home exercise program starts right away. We've run out of time. We've got to get to our live surgery webcast. Thank you very much to our panel members. Thank you very much for all the audience participation.

revision surgery

superior capsule reconstruction

bone cystic formations

anchor placement

P-acnes infection