Well thank you, that was a great talk and Scott's as well setting up really the future. What does the future really hold for rotator cuff repair? And I think the initial answer might be concentrating on a component of rotator cuff tear that we just haven't for all these years. We've given so much attention to implant design and suture configuration and technique, but we kind of forgot one important part and that's biology and maybe that's part of the future going forward. If we look at the present and our use of biologics, we could see that as a literature of the whole we've really studied this, 21 at least randomized controlled trials and at least for my reading the literature, there's just no significant improvement with it. The growth factors contained within it are too short acting and it's not powerful enough to make a change. So what are present as far as optimizing the local environment? Snyder invented and described the crimson veil a long time ago, optimizing the local environment to make it bleed, even microfracture of the footprint. It's thinking biology and if you look at the literature, there's no doubt that it's better, but the truth is that re-tears are still common. Well why is that? Well I think maybe a couple of reasons and if you look at this MRI, you see right below the footprint an area of edema, which really means wash out of the local cells. So even with bed abradement, you could see that the cells might not quite be there near the surface. Hernigo did some studies of the proximal humerus and it showed that patients with rotator cuff tears actually have less of these mesenchymal cells in the proximal humerus than those without tears. So it brings us to the fundamental question, are more cells needed for this biology? If you take two steps back, maybe that's true. There's very little cells in the atrophic rotator cuff. They're displaced from the surface due to the changes of the tear process. So there's really nothing there biologically to control this healing. So it stands now, there's one trial and it's quite a significant trial, a 10-year follow-up. This is Philippe Hernigo's trial where 45 patients in each group and you notice roughly, he noticed roughly double the healing rate. Here's his technique, which is interesting to look at from a biologic perspective. You see the double row repair. You see him pumping in the BMAC or the bone marrow aspirate below the tear and watch what happens when the needle comes out. That's interesting because most of the cells just go away with the saline and with the pressure of the rotator cuff tear. And you can see how easily from the biologic perspective how we can improve this just by coagulating or activating this BMAC to make a gel and you see how much better then it would be of a cellular environment. As a one-up from this and a really a check on that original work by Hernigo, this is Nikhil Verma's and Brian Cole's work here. That's midway through their repeat of his experiment. And this is around 30 patients in each group and it would show slightly better healing in the cellular additional group, but remains to be seen and stay tuned for their final results. We may need to redefine things and we have interpositional grafts that have been used all the time to either lengthen our rotator cuff repairs so they're non-tensioned or even to the point of superior capsular reconstruction. This may have to change in our nomenclature if we have more biologic types of grafts. These would be the so-called sandwich grafts which are deliberately placed between the bone and the tendon to solely be there for biologic purposes such as the holding the cells in place to do their job. This is our new trial that we're starting with this technique. So we're starting with the same BMAC that the other trials are using. We're soaking the BMAC in gel foam, placing directly between an already abraded bed to optimize things and then using standard double row repair. Maybe it's the technique of bone marrow harvest. George Muschler and others have been instrumental to show us how to do this, but maybe that's just the beginning. We know that with this optimal technique that we get 0.01% of cells from the bone marrow. Maybe we could do better in the future. Even with spinning them down in concentration devices, we get a totally different soup of BMAC depending on what device we choose. So we don't even know what kind of cocktail we actually really want as far as BMAC. A lot can be improved. So in summary, biologic environment will need to be optimized because it's the thing we haven't done. Will the addition of cells be required? Will cells need to be contained at the site to be truly effective? Regardless, the future will be giving biology the same attention as we have given those implants and the techniques in the past. And hopefully, this will lead to improved healing rates and clinical outcomes in the future. Thank you.

rotator cuff repair

biology

healing process

biologics

growth factors