Thank you. So I'll try to just give you a few tricks here. Here's my disclosure. So let's go back. So I think of these as sort of conundrum. Conundrum number one is if you have some thin, poor quality soft tissue, how can I pass a suture tape through this poor quality tendon with an anti-grade suture passer without ripping the tendon as you bring your suture out back, suture passer out back laterally. So here you see we have an anti-grade passer. We're going to push it up through. The trapdoor captures the suture. And if you pull it straight laterally, you worry about ripping it. So just get right over the edge as you're kind of pulling up. And then by your needle again, it releases your loop and you can just pull it up more through a supralateral portal. So we'll show it again just over here, a little bit slower, bring it over the edge, and then fire the needle again so it pushes the trapdoor up and you can release that loop that it's caught. And then you can bring it back up at a more favorable angle, at more supralaterally so you're not going to rip it. So poor quality is not the only thing that you have. You can also have a short retracted tendon. So how do you deal with this? So here's a 50-year-old guy who's very active, and he's got this retracted tendon. He had a big stump on the two brasses, so he had a short tendon, in addition to not having the best quality tendon. So what do you do here? Well, you want to provide more excursion, then fix it. So I'll use a modified double interval slide to mobilize it, then a load-sharing rip stop to fix it. So just to kind of go through this load-sharing rip stop, you know, you have a transverse suture that acts as a rip stop for your more vertical suture coming from your anchor. And you can have these be load-sharing if you actually attach your rip stop suture over to anchors laterally. You can do it this way with two anchors, or you can do an individual anchor for each tendon. But the tape is sharing the load, and you're bringing your sutures from your anchor around that tape, which acts as a rip stop. So here's just how you would do it. And this guy, we're doing our posterior interval slide here, all the way back to the fat pad at the base of the scapular spine. That's improved our mobility significantly. Now we'll place an inverted mattress tape. And that's the rip stop that's going to share the load, but also the rip stop tape that you'll go around with your sutures from your anchor. So basically, instead of having a single row repair, you've got a linked double row repair on a short tendon, which is, I think, a real improvement, because now you have a self-reinforcing type of a construct from a biomechanical standpoint. Just to show you how we do it. So you have to get medial to that tape. We'll do the same thing with our second set of sutures. And then you want to reduce the tendon. So what we're going to do is bring our tape limbs around all the sutures from the anchor, and we're going to reduce our tendon over the top of that anchor, and we're going to pull it over to a metaphyseal anchor. So that's helping to share the load, while also forming a rip stop, as you see here. And then you just tie knots here. We'll do that a second time for our other tape, and you see this is our final construct here. How can I stabilize a loose anchor and poor quality bone? Poor quality bone is the other problem you can run into. So you can use a buddy anchor, just side to side, wedging your first loose anchor down more securely. So here we are. This is a rotator cuff repair where we have a lateral metaphyseal anchor. You see as it goes in, it's going to be obvious that this bone quality is really quite poor. Usually these lateral anchors are going to be fine. This is particularly bad bone quality, and you can see it as it goes in. Again the sutures are cutting through the bone actually, and I'm going to take a critical look at this, and I'm really not satisfied with that fixation. So what you can do is you can then take your punch, and you don't want to make a standard hole for the normal diameter of your anchor. You just want to make it about halfway down just to get your anchor started. So it'll go right next to it and wedge it in. And what happens is the threads of the one anchor engage with the threads of the other anchor, and they don't tend to push it further in. It just stays right there and just rides the track on down the anchor. So this can be a really nice way. We'll show that this is quite strong once we finish here. And then you have another set of sutures if you want to use those to come over too. And then if you have a loose medial row anchor, you can use the buddy anchor, but you can also add a linked lateral anchor as kind of a rescue anchor to share the load. So those are just some tips to keep in mind. Thank you.

rotator cuff repairs

poor quality soft tissue

retracted tendons

suture tape

double interval slide