Fact vs. Myth: Remplissage; Latarjet and more (AANA25)-Fact vs. Myth: The Great Debates: Every Bankart Needs a Remplissage; Arthroscopic DTA is the New Latarjet; The SCR Belongs in the Dustbin; All Massive/Revision Cuff Repairs Need to be Augmented

Fact vs. Myth: The Great Debates: Every Bankart Needs a Remplissage; Arthroscopic DTA is the New Latarjet; The SCR Belongs in the Dustbin; All Massive/Revision Cuff Repairs Need to be Augmented

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Video Transcription

Good morning, everybody. You know, we're going to get started on time. There's a lot of, I think, great information to cover. And so, thank you for being here.  We're going to, we call this the Great Debates. And these are, if you're a shoulder surgeon, these are four things you have to think  about pretty much every day as you make decisions. This is my disclosure. We have really an esteemed faculty. And as you can see here, these are the topics.  Remplissage, SCR, DTA versus Laterge, and RC augmentation. All topics that you're sort of seeing presented during the meeting.  And we're going to have a robust debate, followed by a case that would sort of mimic the topic. And then we'll have you guys decide with the audience what would you do.  So, with that, I am going to tell you the format here, as you can see. And then we want to really get started because there's a lot of great information here.  So, with that, I'm going to introduce Dr. Anna Quincy, who's going to start on the Remplissage topic. So, real quick, okay, yeah. All right. Thanks, Ryu and the whole team.  Good morning. We're going to talk about why every bank card needs a Remplissage. These are my disclosures. So, a quick case is an 18-year-old male, injury,  fall from standing, right shoulder dislocation, no prior instability, reduced, nerve vascular intact, apprehension, relocation, things we're all used to.  He's reduced in ER, and these are his x-rays. You can see the little hill sacks there. You get a CT, you get an MRI, all in all, he has an on-track, non-engaging hill sacks defect  with subcritical glenoid bone loss, 11%. And this is the case. The patient comes and sees me and says, Doc, like what should I do? I've had this dislocation, minor bone loss,  small hill sacks defect. I say get a second opinion. He goes to see Jennifer. Jennifer is legit, you know. She's Assistant Program Director,  Naval Medical Center, 2019 Emerging Leaders Society for the Military of Orthopedic Surgeons, first Vice President. She publishes papers on preoperative,  postoperative opioid reduction using multimodal techniques. But she's going to come here and tell us why and how these shoulders re-dislocate with the Bankart only.  She's going to promote arthritis from instability, arthropathy. And I think by the end of the day, she's going to be, her patients are going to be in a multimodal opioid cocktail.  So we're trying to prevent that. So what's the challenge with the Bankarts? High recurrence rate, 33% of 10-year systematic review, 60% incidence of osteoarthritis,  and that's not something we really talk about often with Bankarts. Recurrent instability, collision athletes up to 19%, higher in a lot of studies, 39, I mean up to 40%  in collision athletes, 20% in non-collision athletes, significant risk of instability. Compared to the Latage, the Bankart does poorly.  Unfortunately, the Latage has significant complications that you have to deal with. So what's your other option? Well, the Remplisage. Well, first, do no harm.  That's always what we think about. The Remplisage is safe. Relatively old study here. Ultrasound showing that it heals. The tenodesis effect is real. No loss of strength.  Infraspinatus works perfectly afterwards. Clinically insignificant external rotation loss. Most of these patients do not notice their loss of external rotation.  And with newer techniques, we have brought the loss of external rotation down. It's not what it used to be. So in this study, as we knew, the Remplisage works very well  for large, engaging heel sacks with bone loss of less than 20%. That has always been the tried and true statement in the past.  But we've moved forward from that and applying it to cases that have less severe injuries. This is a systematic review out of Rush. Remplisage versus Bankart alone.  Up to 20% instability. Zero to 20% instability with Remplisage and up to 50% instability with the Bankart alone. High return to sports. In this study, 25 of 26 patients,  professional athletes reported back to sports. I say this is a little bit higher than normal, but still a very high, predictable return to sport rate, approaching 80%.  This might not be true. She's gonna talk about throwing shoulders, I know. But they are about the same. You know, whether you return to sports with a Remplisage or with a Bankart,  the incidence is about the same when it comes to baseball throwers. No difference in external rotation between the Bankart and the Remplisage versus Bankart.  What about all Hill SACs? So small, whatever Hill SACs come in. This is a randomized control study. Peter McDonald, 54 patients in each arm.  Lower recurrence rate in the Remplisage group. Lower revision rate in the Remplisage group. And Peter's gonna join our debate. And let's listen to the master.  There is significantly greater risk of recurring instability in patients who did not have Remplisage for patients with Hill SACs of any size and minimal glenoid bone loss.  So the any size is what we're talking about. In the past, it was used for patients who had large Hill SACs. We've come to realize that it has significant effects  even in a setting with smaller Hill SACs defects. Well, maybe there's a short-term answers. What if we stretched it out to the long-term? Follow-up study, three to nine years.  50%, no Remplisage, 52 patients Remplisage. Similar findings, just more exaggerated. 30% recurrence versus 10%, 22% failure rate  in the Benkard alone group.  So Peter's back. Patients who did not receive a Remplisage experienced a failure earlier and a higher rate of revision and reoperation  than those who received a concomitant Remplisage. So all the experts are on my side. You have to do a Remplisage whenever you can with a Benkard.  Your patient is going to dislocate and fail.  That's what Jennifer is gonna tell you. On-track lesions, small defects. Albert Lin, 56 patients repair with the Remplisage, 127 patients repair alone.  Similar findings, lower dislocation rate. Contact athletes with poor performances. And again, Remplisage works for most patients.  I'm gonna move forward here. High incidence of ill sex. We know that Remplisage is safe. We know that Remplisage is always helpful. Treat out a patient like the high risk  and always do a Remplisage with a Benkard. Thank you. All right. That was great.  And thank you, Dr. Anderquinsey. So Jennifer Smith's gonna give the con to why you have to do a Remplisage.  First, we should start off with, okay, should be knocked down some points because he went over, so.  How do I make this click? There is a- So this one? No, you can just hold it. Yeah. This one? This one. So I just need to hold it. Okay, perfect. Okay, awesome.  All right, so I'm gonna give you the counter argument as to why you don't need to be doing a Remplisage in every patient. First, we're gonna talk about why  doing a straightforward Benkard alone has been proven to be successful and you don't need to be doing a Remplisage in every single patient.  I'm gonna tell you, though, that it does matter. You do need to be selective about which patients you do a Remplisage in and you shouldn't just be doing it in every single patient.  And then, obviously, the main goal of this talk is to make sure to crush okay.  So let's start from the beginning. So Benkard repairs have been proven in the literature to be very successful. They're talking about a 70 to 90% success rate  in those patients that do not have a large amount of bone loss or do not have engaging heel-stacks lesions. Now, that's super important  because unlike what Okay was trying to tell you, those patients had extremely low recurrence rates when you compared it to the patients who did have a Remplisage,  which would indicate that why are you doing a Remplisage? If they have the same amount of low recurrence rate, then it's really unnecessary.  And don't forget, you need to think about the glenoid track. You didn't learn how to do that math and all those numbers for no reason. The glenoid track is extremely important.  This comes down to the fact that if it's a on-track lesion, then it's not gonna engage. You don't need to be doing anything extra. However, when it is an off-track lesion,  it doesn't mean that you should just be doing a Remplisage in every single patient. We know that the literature shows us that when the glenoid bone loss is somewhere  greater than 15%, jury's still out on exactly what that number looks like, it's not enough to just do a Remplisage. You should be thinking about doing something  for augmentation, bony augmentation for the glenoid. So you can't just be doing a Remplisage in all patients. You need to be looking at things like the glenoid track.  And it isn't without risk. Everything we do has potential downfall. And so we have to make sure that we're thinking about those things. And unlike what O.K. was telling you,  the loss of external rotation can be significant. What we're talking about is somewhere between 9% to 14% of external rotation loss,  which for a normal patient may not be that significant, but for an overhead athlete, that can be absolutely devastating. Also important to understand  that unlike what O.K. was telling you, the return to sport rate was different. It's extremely high in a patient who gets a Remplisage, 95-ish percent,  but that number dropped off precipitously to between 51 to 65% for those overhead throwing athletes.  So like I said at the beginning, I'm not saying never do a Remplisage. I'm just saying that you need to decide which patients you should actually be doing them in.  You should be doing them in patients who have engaging heel sacks, off-track lesions, or those high-demand patients that you have a high risk of re-dislocating,  those contact athletes. But you do not need to be doing a Remplisage in those on-track lesions, small, non-engaging lesions, or those low-demand patients  that you know have a very low risk of re-dislocation, or especially in those overhead throwing athletes.  So to tie it all up, I'm not saying Remplisage is terrible. I'm just saying that it can be very beneficial if done in the correct patient.  You need to be looking at every single patient and assessing whether or not their glenoid track indicates that you should be doing a Remplisage or not.  Don't just follow what everyone's doing. Everyone's doing Remplisage. Let's do a Remplisage in every patient. It does matter. You need to tailor your treatments  based on those patients' activity levels and any of their different functional demands. Consider what sport they're playing, what their risk of re-dislocation is.  And don't do a Remplisage in those patients who have non-engaging on-track lesions. The evidence would support that if you go ahead and do a straightforward Bankart,  you're gonna do just fine in the correct patient. Now, like we were discussing, there are some gray areas. There's a lot of us in this room that are participating in the OASIS trial  because we don't know in that subcritical bone loss amount of 10 to 20% whether or not we should be doing a Remplisage or not. So in this study, we're looking at  doing an arthroscopic Bankart, adding a Remplisage, or doing an open Bankart, or doing a Latter Jay. So hopefully at next year's meeting, we'll have some more information  about when you should be doing that. But just remember, you do not need to do a Remplisage in every patient. Thank you.  Thank you, okay, and thank you, Jen, for those opposing views. And let's just see. Here's a case. 22-year-old right-hand dominant college swimmer.  First time dislocation on the left. He was actually celebrating a conference win and dislocated, splashing in the water. He established a Bankart and Remplisage on the right  for instability a year ago. He's got a labral ligamentous tear, as you can see. He's got a small heel sac lesion, far right, little dent.  And now we're in surgery, and this is what it looks like. So you see an indentation, but not a big heel sac lesion. You see some fissuring. So clearly there's been an episode,  and it engaged at some point for that to happen. Here you see a tear. It's more at the labral ligamentous junction.  All right. Show of hands. Help me do a Remplisage on this person. Show of hands. If you believe in it, raise it high. Let's see how many. What do you think? What, one-fifth room?  And maybe half the faculty? The good fifth? The smart fifth? Okay. All right. So here we're going to show you what we do here. So I'm creating a heel sac lesion.  In all honesty, I mean, why not? We're behind on the lateral side of it. We'll go ahead and create one. We'll go ahead and drop an anchor in.  We'll go ahead and do a Remplisage here. The data on Remplisage for me in conjunction with a Bancart is impressive. I've seen it. We do that. Yes, Jen, I'm sorry.  I know you're going to come back. It's not fair that you gave it to me. Anyway, it's impressive, and so we went and did that. And I would tell you that the reason I do this  is when we fail a Bancart, our options are lousy. Every operation you do, if you do a Bancart and it doesn't work, every other operation you do has a higher failure rate.  DTA, Laterge, you name it, revision with Remplisage doesn't work as well. So the primary's got to be the best. So I think adding Remplisage early on,  even in these cases, to me, makes a lot of sense. What do you guys think? I just wanted a quick comment. There's different ways of doing the Remplisage.  And you did, you know, you can check, put that check rein in different areas. If you go more medial, you're going to restrict a lot more than if you just stay lateral.  So if you stay at the level where you put your anchor, a lot of times that's fine without driving in more toward the glenoid. So if you're just doing for a check rein,  you want to make sure you're staying more lateral than medial. Yeah, no, I agree. I think it's a check rein versus filling the defect. The other is the part that always gets to me  is we do stabilization procedures and we talk about, oh, he or she lost external rotation. Well, why is it the Remplisage does that?  I had loss of external rotation with simple Bancarts because I tightened them up too much. So for me, it's adduction, internal rotation ought to be where I'm limited.  So it's kind of the follow through motion rather than the cocking that I can attribute to a Remplisage. It could be simply tightening up at the front of your shoulder  and you lose external rotation. So I've always had a problem with the motion loss issue. And how do you say, oh, I did a Bancart, I did a Remplisage,  I lost external rotation, it was a Remplisage. You know, I don't know. Anyway, it always puzzles me. I agree, I don't really know the right answer  in throwers other than trying to keep it more lateral. So maybe you don't over tighten them. But I heard Albert Lin say once, if you add a Remplisage, what's the worst that happens?  Maybe they're a little stiff.  If you don't add a Remplisage, what's the worst that happens? They re-dislocate. So it's like, I think the lesser of two evils. But I do agree, you have to be judicious  in who you choose, Jen. Thank you. I did not choose which argument side I got, okay. All right, so with that, we're gonna move on to the next topic.  And I think we're gonna be discussing Latter-day Versus DTA, is that right? No, no, hey, hey, I'm glad you could join us, JT.  Thanks for coming.  I've been here, I just didn't have a chair. So I had to sit in the audience. I just was looking at your Remplisage, and it looks much more like a ligament of Terry's reconstruction,  because you put that right in the center of the humeral head. So I'm trying to figure out,  I'm trying to figure out exactly what that was, or what the French name for that is. You showed me how to do that. That's right. No, that's great, that's a great case.  So I think we're gonna move on to the next topic. And I think, is Bill, are you up first? Okay, great. Go to Dr. Saccone's slide, please.  All right, thanks, Rick and everybody. This is a great session. It's always great to have everyone here. So we're gonna talk about arthroscopic DTA as the new Latter-day.  And I have to debate Dr. Gettleman, which is always scary to do, because he's an arthroscopic innovator, past president of ANA. He's fellowship director.  He's trained hundreds of great surgeons. And he's a businessman. He's taught us all how to do single row rotator cuff repair and save the lateral rows.  We can save money in our centers and crimson duvet, microfracture. But he's a little bit biased. He trained Ian Lowe. So he's a little bit biased.  There's a little bit of conflict of interest there. So you have to kind of take with what he says with a grain of salt.  So I would just say that DTA is not the same as a Latter-day. Latter-day can eliminate the glenoid bone loss. It has a sling effect.  You inferiorize the lower border of the subscapularis. And you have the conjoined tendon. These are not the same procedures.  Graft placement in the Latter-day is a bit easier. We know that graft placement is important. If you place a graft lateral, you tend to get arthritis.  If you place it too medial, you still dislocate. So you have to be able to place that graft in the right area. Now, the subscapularis split is an issue.  I'm showing an arthroscopic Latter-day here. It's important, and it's also the risky part of the seizure, but it also allows you to get the graft  in right the direct position you want to put it in. In the, and as you see here, we're putting the graft down. You can get, with a scope, you can get a good visualization  of where you put the arthroscopic Latter-day.  For the DTA, the described technique, which is a safe technique, is to come superior to subscap. So we're looking down here at glenoid,  where you have the switching stick from posterior. You come over top of subscap. Instead of going through the subscapularis, but you have to be able to push it down.  You have to do it, inferiorize that far enough down to make it to that inferior portion of the glenoid, inferior half of the glenoid. That can be really hard to do.  So what it does, when you first start these procedures, if you're not doing an adequate subscap release arthroscopically and you're not doing those things you need to do,  you're going to put that graft high. And what's worse than doing a open Latter-day or trying to do these arthroscopically is putting the bone in the wrong area.  That's not helpful, and that's not an easy thing to do. In addition, when you do a distal tibia, you have to bring the graft from the outside in,  whereas in Latter-day, the graft is already in the shoulder. So going from the outside in is also difficult. Coming through the pec major, you have to make an incision  and come directly through the pec major muscle to get that graft in there. That can be difficult as well. And then, you know, they'll make an argument  about the cartilage is important. However, in the described technique from Dr. Wong,  they put the cartilage, they repair the labrum over the top of the native glenoid. So apparently, the cartilage is extra-articular anyway. So I guess that doesn't really matter  whether or not you actually have cartilage because they're making it extra-articular to add stability. If we look at outcomes of Latter-day  versus distal tibial allograft, no differences. Complications are the same in these meta-analyses.  No differences in recurrent instability, surgical complications, arthritis progression, or return to sports.  You look at scope Latter-day versus arthroscopic free bone block. No differences in recurrence or complications.  However, when you do the Latter-day biomechanically, you get extra things that go along. You get the sling effect. So in this, the authors recommend the Latter-day  to restore stability with glenoid bone loss, not the free bone block.  If you look at a dynamic testing, unloaded Latter-day stabilized 75% of specimens just with the bone. But if you load it, it stabilized 100% of the specimens.  So from my perspective, even though if you look activity levels and all things seem to be the same, if you're going to have a contact athlete, you want more.  You want to be able to get more out of your procedure. So I think with the complication risks are about the same, and maybe they're a little bit more with the Latter-day.  You get better at those. I think that's probably the better procedure to do. Mark's going to make an argument about the subscapularis  and about how it's all terrible with the Latter-day. Here's structural and functional results of subscapularis and conjoined tendon, eight-year follow-up.  Comparison to the non-operative shoulder, no difference in internal rotation, normal subscap muscle girth, and conjoined tendon is still intact.  So again, Mark's a great innovator, but he's also a wine connoisseur and a watch collector. We mentioned before he's a good businessman.  However, Mark, I think you could spend a lot more money if you didn't buy so many allografts. I think you'd be a lot better. Thank you. Thank you.  All right, can I get my slides and make sure the audio's all the way up, please? So you know, Bill's a good guy.  He's the education chair, so I have to be a little bit nice to him to stay on the program now that I'm a past president and a dinosaur, almost as old as Ryu.  So you know, here's the options for our debate. We had to talk about, you know, the latter J and open or arthroscopic. And I'm really talking about an Eden Hibernate.  And so there's lots of different ways to think about that. And yes, you've heard there's still controversy out of how to best manage this.  And you know, Bill and I have spent a lot of time talking about that. And I just want to show a little excerpt from our last conversation here when we talk about this. Back, please.  All right. You screwed with my slides, I can tell.  Can you hit play, please?  You want answers? I think I'm entitled. You want answers. I want the truth. You can't handle the truth. So Saccone used to look a whole lot different when he had hair.  And he was actually smarter, I think, back then, too. He understood what the right answer was. But he can't handle the truth.  Nobody wants to do a latter J. And so the open Iliac crest was pretty easy. Eden-Hibbinet, as we called it back then, J.P. Warner published on this many years ago,  and found that the risk of recurrence is really small. You put the thing intra-articulately, and this was open, and you had really good outcomes.  But there was this potential risk of loss of external rotation and incidence of OA. And so the Eden-Hibbinet is now the AAGR, where we're doing an arthroscopic anatomic  glenoid reconstruction that is safe, most importantly safe. You're not going to hurt anybody like you can with a latter J, and effective.  And if you look at Ivan Wong, just from yesterday's talk from the podium, what he showed us is  a randomized controlled trial that shows it's equally as safe as an arthroscopic Bankart.  How many of you spend up nights before the surgery thinking about your arthroscopic Bankart? Zero. How many of you are stressed out about doing a latter J the next day?  Everybody in the audience, right? Because you're worried about these nerves, and you're worried about these things that you have to think about. And what about the sling effect?  The sling effect has some role in shoulder stabilization, but it is truly the bony block effect that is the key to the latter J's effectiveness. That's from CHAT-GPT.  It has to be correct. So I'm on CHAT-GPT's side. And so when we think about the bone graft versus the dynamic stabilizing effect, the  sling effect is real, and it's important if the graft is in the right spot. And when we talked to Ciccone, what is the elephant in the room? He didn't even talk about risks.  Risks are what it's all about, because that's what stresses everybody out. And if you have a complication, it's a disaster. And the open complications are real.  Neurovascular risks are real. Musculoskeletal injuries are real. Axillary nerve injuries are real. And then the subscap, if you get scarring, you're going to limit ER.  And if you get iatrogenic damage, you're also going to limit internal rotation, and you have to get that graft in a perfect position.  And so as an arthroscopist, and Bill is technically excellent, we want to do this arthroscopically. And so it's difficult.  You have to be completely comfortable with the arthroscopic anatomy. You have to do it in the beach chair position.  And it requires the scapular protraction to get your graft in the right spot. It's technically really hard.  You have this alphabet soup of portals, and you are spending a lot of time medial to the conjoint tendon, which makes people a little bit nervous as well.  When we talk about the subscap, you're not splitting the subscap. You're annihilating the subscap.  You are taking radiofrequency and blasting through the middle third of the subscapularis. The distal tibia is a great operation.  You know, Tokush won't say it, but Matt Preventer was right on this. This is really, you know, something that's significant. And when you do it open, it's pretty easy to do.  You don't worry about a lot of these things, and the approach is completely safe. We can do it lateral decubitus, which we like doing better for instability anyway.  You can prepare the graft. There's lots of options. If you don't want to spend money on allograft, you've got autograft options. The distal clavicle is a great graft for this.  But you have lots of different things that you can use. And you can do it either with screws or buttons, and you can think about how to doing it. It's very safe.  You don't mess with the subscap at all. And Ivan Wong, who was one of my former fellows, well, I'm now his fellow when it comes to this, because this is absolutely the way to do it.  I do make a Halifax portal, which you have to go through the PEC major. But it's really easy. We basically had an easy short learning curve with doing this technique.  We get the graft in the right spot. And my algorithm is now DTA pretty much routinely. So here's what we do. We prepare our DTA.  We go ahead and make a Halifax portal, put it in medially. And then this is what it looks like. Can you hit play, please? And so we can put the graft in.  And then, yes, if you're using a frozen graft, which is what this is, because it's cheaper so I can buy more watches, we go ahead and put the capsule over the top of it.  And we can get that in the right position. And so this is what it ends up looking like at the end. We can get x-rays intraoperatively to make sure we're in the right spot.  Post-op x-rays look great. And Saccone put this slide in, I think. He says it's awesome. And he's likely right. But we know that the AAGR is the correct answer.  Can you hit play, please? And so Bill, again, when he was a little bit younger, we went ahead and spent some time and we talked about this at the end of the day.  And we finished conversation. He basically said, I think you're right. And so I think, Saccone, you've been knocked out, buddy. Thank you. Thank you. Can you read my DECA, please?  We'll go to the case regarding Latter-Jay. And I got to tell you, can you go back some slides, please? Should I go back? Here we go. So thank you, Bill. Thank you, Mark.  This is a real interesting topic, because I think Latter-Jay is a great operation. I've done it for a long, long time. It's a great operation.  But the DT, I got to tell you, there's some traction there. And Ivan Wong's to be congratulated on his sort of being a leader in that field.  So this is a 30-year-old right-hand dominant male, had initial dislocation, surfing in 2014, about 10 years before he saw me, self-reduced.  He's had six episodes since that time, again, all self-reduced. You can kind of see some of the images here. And basically, if you put it all together, it's a near-track lesion.  The glenoid bone loss is felt to be probably under 15%, so somewhere around 10% to 12%. But it's approaching the distance to dislocation worrisome zone.  So this is what it looks like. Here we are, pretty large heel sac lesion. Look in the front, and he stripped it off. He's got like almost a type 5 slap-type configuration here.  And so the question here is, what do we do? So show of hands, how many would say, hey, this is Latter-Jay all the way? You know Latter-Jays? Come on.  Put them up if you want to do Latter-Jay. Guillermo? Latter-Jay? Okay. How many would do a DTA? I'm going to ask, how many would do a Remplissage with a Bankart?  Remplissage with DTA. Okay. But wouldn't know a DTA. So right now, it's basically, most people aren't going to operate on him, from what I can see here. Remplissage, I love that.  Okay. All right. So, and that's a very interesting thing we'll talk about, too. So here we are. So here's a Remplissage.  And I got to tell you, you know, it's kind of, I pretty much do this on almost every instability case. Here we're doing a transglenoid technique. It's a double-button technique.  We're going to drop our graft, and we spare the subscap and seed our bone block. And once we get this bone block fixed here, you'll see we're pretty flush, and it looks pretty good.  And this is going to be extra, so we use frozen. We do not use fresh. It's very inexpensive, relatively speaking. We're extra-articular. Here's my Bankart lesion.  And as Mark just showed you, we bring it up and over, so it's extra-articular. So cell viability is not an issue.  So here you see Remplissage in place, and then you see our Bankart in place. Our bone block is extra-articular.  What's interesting is that these patients oftentimes have very little motion loss. I was very concerned about that, but I'm not running that as being an issue, despite the  extent of this kind of surgery. All right. With that, comments from the panel regarding... Bill, go ahead. I just want to say something.  I mean, I'm defending Latter-Jay, but Mark's points are valid. The Latter-Jay has significantly higher complication risk than the DTAs.  And for these patients who have instability, who are not contact athletes, and are not really dependent upon all of that, the DTA is the way to go. Yeah.  Well, I think one of the issues really for me is, you know, in orthopedics, we always head towards how do you restore normal anatomy?  So the minute you start distorting anatomy, you know, it, I think, ends up being this...  You know, if you look at the data on arthroplasty after a Latter-Jay, none of it's good, late OA, none of it's good.  So you want to restore normal anatomy, and I think DTA kind of gets us closer to that. But if you have lousy soft tissue, that's where Bill's operation comes in place.  I think the Latter-Jay, the sling effect, et cetera, really does provide something. But if your tissue's pretty healthy, I'm not sure you need to necessarily deform anatomy  to get where you need to go. Any other comments? JT? You normally have something snarky to say. Go ahead. No, yeah. I love this. My worry right now is about resorption.  So the graph looks beautiful here at time zero. It's not going to look like that in 12 months to, you know, to 14 months. I struggle with this, too.  The advantage of the Latter-Jay or the screw fixation is that when that bone does go away,  the screws are a nice rebar, and that's probably why the dislocation rate doesn't happen, but we're worried about that, too. We haven't yet figured that out.  We don't know about allograft versus autograft in terms of that's the one advantage of the Latter-Jay maybe.  I mean, Ivan's work and others' work, we've seen it ourselves that the healing rate is good, so be careful when we see healing rate because it does heal at the seam, but that's  very different than the resorption area. We're now calling it remodeling because it sounds so much nicer, so much more sedate when we talk about it'll remodel.  But sometimes these just fall apart, and we don't know yet why and when.  And I think that's the next frontier, but if we can figure out how to get that bone to stay, well, then I think we've won the game.  Well, you know, I think a paper at the shoulder level talking about fresh versus frozen allograft,  no difference, you know, 100 of each, I think, showing no difference in outcomes because one of the issues, as you and I both know, that you do a Latter-Jay, it's a vascularized  graft, so that's a real advantage there, right, doing a Latter-Jay. And at the end of the day, resorption of the Latter-Jay does not correlate with recurrent instability.  No, because screws don't resorb. But you really think the screws are holding the head in? Yeah, I do. I mean, when you look at Ivan's work right now.  Maybe in your operations, but I'm going to tell you, the screws bend. In Ivan's operation, right, so when he looked at his same technique, same surgeon, same  everything except buttons versus screws, there's no other explanation for why he has such a higher failure rate.  It wasn't resorption, the autograft or his screws just resorbed just as much, 50% overall  when he looks at his overall graft. It wasn't a healing problem when you take a look at it. So the only difference I see is that he's got rebar that's left over after that, and  so that's one I think we've got to figure out. Well, his talk terrified me, so I stopped doing this operation until I got two-year  follow-up on my first 20, 25, because I don't want to run into trouble. And I've got to tell you, I have not run into that issue. I would agree.  But anyway, that said, I think there's a lot out there for a lot of meat on the bone. It's a good time to be a shoulder surgeon. Exactly right.  So with that, I'm going to go to the next topic, and I think this is going to be the SCR. So I think we're going to start with Kevin Bonner and then follow with J.T. Thanks Rick.  So my sort of charge is to debate J.T., and my charge is to make the argument SCR belongs in the dustbin. I do have some relevant disclosures, by the way.  So debating J.T., a lot of people said- This true case of David and Goliath is unbelievable. The condition of those men. I must break you. You're going to have a walk.  So yeah, a little bit intimidating. He's a smart guy. And so basically, if we went back and we were having this debate six or seven years ago, I'd be in trouble, honestly.  So Tarun Mahada obviously came up with the procedure itself. He had some great biomechanical work done on it. And to be honest, nobody has replicated his results in the world.  And then if you look in the United States, also initially generally very positive surgical outcomes for a very challenging group.  However, when you look from very high level surgeons, no one has really replicated Steve Burkhart's work here in the United States. He had the brass group.  And if you look back, Steve even had a talk back in 2016, SCR is going to change everything. But again, nobody in the United States has really replicated Steve's results.  They might have to stop this one before somebody gets killed. So if we were having this debate six years ago, this would have been me and J.T. just humbling me. So what happened?  What happened with SCR? So it showed promise. However, the evolving data and clinical experience are reshaping opinions over the last six to seven years.  It's technically challenging for everybody at a very high rate of non-healing and re-tearing as I'll show. And why are they doing well clinically?  There are less demanding alternatives that people can perform. And if you look, Buddy said this, you know, years ago, if you actually remove Mahada's  data, the results of SCR with dermal grafts are really no better than a well-done partial repair or tendon transfer. Can we change to the next slide, please?  And so what is the most common complication? Yes, clinically, they're doing well. But if you look across the board, the non-healing of these SCR grafts is anywhere between 20  to 70%. And a 70% is not an outlier. Very commonly in the 40 to 55% range, these are not healing, but they are doing clinically well.  And if you say, well, you're not doing well in the United States with allografts, but what about autograft? Well, everybody has not replicated Mahada's work with autografts.  And so even with autograft, this is the group out of Korea, basically 62% rate of graft tearing. So even with autograft. I'm so happy with the pain, no pain at all.  So this was one of my patients five years after I did an SCR on him. He was very, very happy. But when you look, his SCR actually never healed. So it failed on the glenoid side.  So a big discrepancy between clinical and radiographic results in SCR. And then Albert Lin did a lot of work saying, well, is SCR actually doing in vivo what we think it is?  So we think it's going to depress the humeral head. When you look at his work in vivo, it's actually not doing that. So Albert did some great work.  There's a great in vivo study showing that it's not doing it. And then if you look at SCR, this is another article from Albert Lin, the SCR actually elongates over time.  So where you put it at time zero is not actually where it winds up at one year later. So again, more and more work that SCR is not doing what we initially thought.  And so here's just another one. So Raffi started looking at this. And I credit Raffi for a lot of this.  And we published at the same time, I'll show you, on doing a different type of procedure. But basically showed that if the tuberosity was covered, those patients were actually  doing just as well if the SCR had healed. And so this is with Albert, again, SCR has really fallen out of favor.  So if you look now, a lot of us were doing SCR, you know, seven, eight years ago when we're not doing it now. And so things changed.  So more and more of us were finding other procedures that were a lot easier to do. But we're coming out with the same results. We published on this. Raffi published on this.  We're actually publishing our combined results at this meeting, actually. Five and a half weeks ago.  So tell a big difference compared to this guy's five and a half weeks out on just covering tuberosity and not doing an SCR. And it's a very easy operation that everybody can do.  And this is the combined group that Raffi is going to present here at this meeting. So no revisions or conversions to arthroplasty, 54 patients.  And again, if I said, hey, this was an SCR group, you'd say this is a great result. But the thing is, we did not go to the glenoid side. We just covered the tuberosity.  And this is the group, the SFA is actually the French Arthroscopy Association.  They came out with a position statement on SCR and basically said, yeah, the clinical results are good, but the radiographic outcomes are poor and it's not doing what we think  it's doing. And there's really no proof that it's better than a partial repair. We published this study a couple of years ago and we presented it here at ANA a couple  years ago, where more and more people are becoming disenfranchised with SCR and effectively it's going away. Maybe all we need to do is stick in a spacer.  And a smart guy said, maybe we just have to put a spacer in and that's all you need to do. So if you ask some of the reps, and I'm on the board of LifeNet, and they keep close  track of this, basically nobody is doing SCR anymore. Even the guys who were big proponents a few years ago, they haven't done them in years actually.  So why have surgeons moved away from SCR? It's technically challenging and expensive. Nobody has replicated Steve Burkhardt or Mahata's work.  Nobody is going to tolerate donor morbidity with autografts. High failure rates up to 70%. Dermal grafts weaken and stretch. It's likely not doing what we thought it was.  And if it's the spacer effect, there's a lot easier alternatives. And the critics, again, it's really not proven to be any better than a partial repair or debridement.  And it's effectively gone up and down what's called Scott's parabola. So thank you very much. Oh, JT, that's a big hill to climb. All right, man, go ahead.  Man, you know, the problem with Kevin, he's so good looking, it's so smooth that you didn't even notice that he put his face on Rocky Balboa's, right, because it looks just like  Rocky Balboa. Everybody noticed that I'm not Ivan Drago, and they're like, who's the kid with the big nose in there?  So it's an unfair debate from the start. And Kevin's smooth, man. So I'm going to tell you a little bit about why he's lying to you through his teeth.  And the first is, in terms of disclosure, I'm going to tell you that all the surgical video and most of the other video in this presentation is unaltered and unadulterated.  SCR for sure has narrowing indications. And the problem is, is that you guys, and especially Kevin, have just lumped it all together. And I'm going to explain to you why.  There are indications where the SCR is still your very best technique. But it's narrow, for sure. And we'll go into the reasons as to why that is.  I don't want you to be lulled into a false sense of security by Bonner's soothing voice. Could you run that video, please?  He was Navy PSYOPs before orthopedics, and turn up the volume, where he soothed in many a confused mind. Oh, that's going to suck if that doesn't go.  That's unfortunate. This is Bonner after just getting out of the Navy. I never liked SCR. I only like happy little cases. SCR stressed me out. I like the little ones. And weed.  Yeah, I mean, there's a reason he got out of the military a little bit early.  But I mean, you know, I mean, you can see, you think he's Rocky Balboa, but he's really Bob Ross in this situation. I'm just going to take you through the treatment algorithm.  And here's the problem with SCR is everybody goes, Oh, it's a massive cuff tear. And so you could do an SCR or you don't do an SCR. And I'll tell you, it's not the right answer.  So, for example, I will just tell you, you got to answer four questions. The first is, do they have significant DJD? And if they have significant DJD, just do the damn reverse.  It works great. OK, but everybody goes, Oh, people try to do SCR. And many of us did with a little bit of arthritis doesn't work. Do the do the reverse.  So but nobody wants to talk about that. And that's what not this debate is not about. The debate is about, OK, what if they don't have significant DJD?  Well, then I tell you, you got to ask one of two questions. Are they older or the young? If they're old, just do the reverse. It works fine.  It's not part of the algorithm, but nobody wants to talk about that either. We want to talk about the young patient. And so in the young patient under 65, very active.  Then I would ask you a question. Are they functional or nonfunctional? And here's where Kevin leads you down a primrose path and where all of these guys do.  If you're functional, meaning you show up here today and you have a, quote, massive cuff tear on your MRI and you do this, right?  You'll notice Kevin didn't show you any of his pre-ops.  He just showed you the post-op. The guy going, I love it. I love it. Well, if you'd have looked at him pre-op, he'd have said my shoulder hurts.  But his freaking shoulder would have been up here. Why? Because Rafi with the tuberoplasty, cutting the biceps, any of the patches all require you to have pre-op motion.  Well, that's easy. And we did the systematic review on this. There's 17 different studies in the literature that you show me with a massive cuff tear.  And as long as you can raise your arm and you're still functional, you can do anything you want. You can spit at it. You can do rehab with it. You can do seances with it.  You can do hot yoga with Kevin with it. All of it works. So that's bullshit. That's not what we're looking for. We're talking about patients who are non-functional.  And in that patient with the non-functional, this portion of the algorithm,  none of the used cars that he's trying to sell you will work. Rafi won't do a tuberoplasty in this part of the algorithm.  And this is the part of the algorithm that's in your clinic and in my clinic.  So I'd say I would say this. It's perfect. The SCR is perfect for the non-arthritic, active, non-functional and alive muscle or what I call Nana's tear. All right.  So if you got your Nana, Kevin's a good Italian boy. He understands these things. If you've got Nana, meaning that she's trying to lift her arm,  but she's young and still wants to do it and can't lift her arm. Don't give me any of your nonsense about what you're going to do  with little patches or stick something on there and hope it's going to work. It ain't going to work. So what are your choices? Why are the other choices losers for your Nana?  Well, reverse is a loser because these are patients with no significant DJD and they're active and they're young.  Kevin's approach with balloons or biceps is or tuberoplasties or rehab. All those are losers for your Nana.  And the reason they're losers because they're non-functional and they're weak and they're all contraindicated, not even controversial.  Even the purveyors of these techniques would say we won't try them in this. Finally, the lower trap transfer, which is the computer for this, if you will.  This one is not a good choice when you still have an alive muscle. And Basim and I argue about this all the time. He says, well, I do the lower trap  because it's the best transfer in phase for a week. Infraspinatus. And I said, well, no, it's not the best transfer for the infraspinatus is the infraspinatus as long as it's alive.  Right. So if you've got that patient with that, with that non-arthritic active and your muscle is alive, then your best choice is the SCR still today in 2025.  And that's why the results aren't reproduced, because the results are comparing apples to oranges and we have to do that. So SCR versus RSA, if you're talking about without  without degenerative joint disease, this article just fresh off the press. JSCS 2025. If you have a young, active patient, SCR beats RSA in this situation.  SCR versus lower trap transfer. And this is from the institution itself that described lower trap transfer compared SCR versus lower trap.  SCR had lower VAS scores, better forward elevation, forward elevation strength and no difference in the complication rate.  So in this portion of the algorithm, nanostare, you've got an SCR that's superior, if you will. But we do an SCR as a as an extension graft as well.  Even in the systematic reviews that are out there, SCR beats LTT when you compare those patients in the right area. So when is the lower trap transfer better than the SCR?  Well, when the muscle's dead. I always say if there's no muscle, there's no hope. So if that is dead, you got grade three, four retaliate changes and the patient is nonfunctional.  Well, then the SCR won't work. Well, neither will anything else. And that's the one little sliver where you get the lower trapezius transfer in there.  But the patch ain't going to work for that. Show me somebody that's going to put a patch or one of the one of the techniques  that Kevin describes in a patient who has no motion like this pseudoparalysis and a dead muscle. It ain't working. And they don't even try it. They'll tell you that.  Well, we're not going to touch that one. Well, that's everybody. That's the whole point of these discussions, if you will. So when the muscle is dead, but this ain't your nanostare,  no arthritis active in a functional and alive muscle. This is your dead muscle. Active patient, massive, nonfunctional, decreased ACR.  And so in that patient, that's the damned portion of the allograft. So if you're damned, go ahead and use that, if you will.  So the lessons learned on these things, we'll go through those things fast about how we do this in the prep and everything else.  And then we'll just get there. And if you can do this, then this is what you can do. You can reverse pseudoparalysis with this. None of the other techniques do this.  So those are your lessons. SCR can be a game changer. The indications are critical if we talk about it. It is technically demanding.  And I will say Bonner's come a long way in terms of Anna all the way to the presidency. Thanks, Ellen.  What are you doing in my office? You know, I'm the president now, right?  I'm kidding. I'm kidding. Maybe not. He is tech support for Anna. I congratulate him on his ascension to the presidency and appreciate the chance to debate you, buddy. Good job.  All right. What's your your pre-op and your post-op video? They're the same video. You just pause to the pre-op one halfway up. She was pre-op. We did the surgery. We fixed her.  Well, to take on that functional issue, giving them a subacromial steroid injection will also convert some of these into the functional range.  So when they're like this and they're getting to hear it, I'm not going to pseudo paralysis, but to hear pain can stop them. And if you relieve the pain and they get to hear,  you're in the functional group again. So you just can't use this as your criteria. You got to take away the pain to see if they get higher.  So it's important that you do that test so that you don't fall into doing an SCR for someone like this with a little lidocaine is like this.  Anyway, I'll throw a quick question out there. So, John and Kevin, so can you talk about the role of the Terry's minor in your evaluations of these patients,  of whether or not hypertrophy or atrophy Terry's minor changes your  indications or your treatments?  No, I mean, honestly, I think that you see it.  And it's not uncommon, as you know, but honestly, myself, I focus more on the infraspinatus and their external rotation strength.  But the Terry's minor itself, I'll sort of assess that with the infra. But that in my algorithm doesn't doesn't change a whole lot. So so I would tell you that that doesn't matter.  You should take a look at what the patient's doing. So if the patient can do this and sometimes they can have grade four infra  and the Terry's minor's hypertrophy and they can still do this. In this case, you have a functional cuff tear. Well, then you can do anything you want.  Biceps, patch, balloon, anything works. But but if you have a patient who does this, then you have to look at that MRI. And if the and if the M4 is dead, SCR won't work.  Then then you got to do the lower trap transfer. But if that SCR, if that is alive, that's where that's where the SCR has got a sweet spot.  So I'm going to go to the case and we'll do this. So basically, here's a 71 year old gentleman.  He's got weakness and pain. He's an avid golfer. He can actually play, but he's symptomatic. He has pain. Retired mailman, healthy, active.  And you can see on exam here, he's got pretty much everything working, but is SST. So here we are taking a peek, trying to make some decisions, biceps intact. He's got a bald eagle.  He's got a decent external rotation.  And there's a lot of things we can do at this point. But mostly he wants to play golf and he has pain, but he has a full range of motion, so he's functional.  He's based on the range of motion. So with that, I'm going to ask how many people here would say  this guy is a good candidate for an SCR? Anybody in the audience? Anybody?  How about, yeah, Guillermo, you would do an SCR, all right.  Well, when Guillermo says he's going to do an SCR, I start rethinking things because he's the smartest guy I know. So I don't know if there's something going on here.  Guillermo, can you share with us why you would do an SCR? Guillermo's from Argentina and one of the thought leaders in the world on this topic.  I think that it's functional and the problem is with pain. The SCR of the little black thing may work well.  Okay. All right. I also paid for Guillermo's business class ticket to say he would vote for SCR on this. So just so you guys know. Hey, Rick, what about interpositional graphs?  I feel like there are a few studies coming out recently. It's almost like trying to bring the dead back from where they... And I agree. And Mark has tremendous data on that.  And he kind of clued me into that as well. And muscle biobasic, muscle biobasic, muscle biobasic, And I agree. And Mark has tremendous data on that.  And he kind of clued me into that as well. And muscle biobasic is a big deal. I think with JT, I think the interposition, quite frankly, in those cases,  may be better than the SCR if you have live muscle. And you go from the edge of the muscle to the tuberosity.  And the bridging graph, there's a lot of data saying that's a great operation. So when I see live muscle, I'm thinking more interposition, quite frankly.  Every one of my SCRs is an extension graph. We always type. You bring it over. Yeah. Okay. All right. So how many here in the room would do something else?  Balloon, tuberoplasty, show of hands? If I did a large field, I'd move the biceps over and try to bring the spinatus up. So a bio-SCR type thing.  Partial repair with the tinnitus of biceps. But in this case, because he's functional, that's a lot more than you need probably.  Just do the balloon or do the patch or do the tuberoplasty. I'm trying to give as much functional message. Well, you know, this is the thing. We face this every day in our office.  These decisions are tough because the menu that you can choose from is incredibly long. So I'm really grateful to have this conversation. I got to tell you, I struggle as well.  So what it comes down to often is some basics of functionality, OA, but it's your patient. What does your patient need?  So we decided doing this fellow is simple, very simple, drop a balloon in. And I got to tell you, it's a great operation and the right patient.  Five-minute procedure, and they do very well. Their pain is remarkably improved.  And at least some of the recent published studies show five, six-year results at 75%, 80% are still doing well. So anyway, what do you guys say? Balloon, not appropriate?  If the patient's functional, it'll work. And I agree, and it's a simple operation.  And believe it or not, the balloon is the one operation that the government's actually pushing for. If you look at outpatient reimbursement to the centers,  it is one operation that every year gets reimbursed more and more and more. It's very interesting. So there's almost a push to go to the balloon.  All right, we're going to last topic here, and that is going to be rotator cuff repair, vision's massive, and whether you should augment.  And we're going to start with Professor Lowe. Are you awake? Yeah. All right, okay. I didn't know I was starting, sorry. All right, grasshopper. I'm a con, right? I'm a con.  Hey, thanks. JT, you want to stay up? I'll sit over here. Okay, all right. Thanks, Rick. My disclosure's updated in this new system.  Okay, everybody knows that Michael O'Brien likes to portray himself as a really, really nice guy. He's kind, he's polite, he's intelligent, he's well-dressed.  He wants us to think that he's pretty much the angel of the orthopedic community. But I know a different Michael O'Brien.  I know a Michael O'Brien who's a chain smoker, oyster glutton, and the type of Michael O'Brien you don't want to hang out with.  I know a type of Michael O'Brien who will dance the night away in a euphoric high of malapack oysters, Cubans, and Old Spice. And honestly, would you trust this guy?  This is the type of evil Michael O'Brien would basically say anything, that even grass can help. But we all know that massive rotative cuff tears are bound to fail.  You can see here, here's a massive rotative cuff tear, subscap, supra-infra. It's under tension. We can only get it to the medial aspect of the footprint.  We do, you know, one of those scobey repairs with ripstop sutures. And I put this magical cal graft on top. It's definitely going to work, right, Mike?  Well, here's the postoperative MRI. Obviously, re-tear, patient required a reverse. Because we know that massive tears just don't heal.  You can see in this multicenter study here, 256 patients. Even in the best case scenario, massive tear, 50-year-old, 43% chance of healing. And there's a lot of grass out there.  And we know they can all help from a biological or biomechanical perspective. But really, no grass has been shown to be effective for a massive rotative cuff tear.  What about this thing? Well, this thing, of course, is the hottest thing out there. Mike's, I'm sure, going to talk about this. Why do we like it?  We like it because it's easy to put in. But does it work? Well, yeah, sure. Of course, it can work.  You can see in this prospective randomized trial, this is probably the best evidence out there. The Ruazi-Bahn study, you can see that the re-tear rate went down from 26% to 8%.  Sounds really, really good. But when you look at the inclusion criteria, only rotative cuff tears between 1 and 4 centimeters with no sub-scapular involvement.  Obviously, therefore, this is no evidence for a massive tear. What about this study? Oh, this is Michael's study. I know he loves this study. He's probably going to quote it, too.  23 patients, large and massive tears, 96% healing rate. 96%. That's crazy. No control group, 96%. I can't even get my partial tears to heal at 96%. This is what I think. Bleh. OK.  What about other studies? Human dermal allograft. OK, because you think that because I have better biomechanics, maybe you're going to do better  with your massive rotative cuff tears. Well, potentially that's true. This is the classic study here. It's pretty old right now. The Barber study.  You can see human dermal allografts, better healing, 85% versus 40%. What was their inclusion criteria? Well, they said two tendon tears and greater than 3 centimeters.  But does that look like a massive tear to you? This is from their study. That doesn't even look 3 centimeters to me. So I'm not really sure, really, what they were studying.  In fact, if you look at this meta-analysis here for A-cellar matrix dermal patches, a whole bunch of prospective randomized studies, you can see you can decrease your E-tear rate  from 35% to 11%. But look at the tear size. Again, just 3 centimeters. So this is not massive tear evidence. OK, maybe you're not a graph guy.  Let's just add stem cells, because stem cells will help. But you can see here, the classic study, Hergenot study, healing rate increased to 87%.  But look at these, just tiny little tears, 1.5 to 3.5 centimeters. Same thing with the Cole study. It did decrease your E-tear rate. But again, we're talking very, very small tears.  So you've got to start to think to yourself, why is there no evidence? There's no high-quality literature for massive rotative tears in a graph.  None of this, collagen matrices, don't even talk about PRP, BMAC, collagen implants. That's basically because augmentation doesn't work in massive tears.  Because it's not just a drop in a bucket, it's basically a drop in the ocean. It just has no effect. I did just lie.  There actually is one study, collagen implants for massive rotative tears. You can see about 50 patients. These are truly massive tears.  2 to 3 centimeter tears, greater than 4 centimeters from an anterior to posterior direction, greater than 2 centimeters retraction. This is a SAMR study.  You can see here, there was no significant difference. And then the healing rate, oh, guess what? Right, no significant difference.  So in the end, graphs can help, but really just for smaller tears. Massive tears are a completely different beast. There's no evidence to support their usage.  That's because, really, we don't have the optimal graph yet for a massive rotative tear. Thank you very much.  All right, Mike, tell us why it's a must that we have to graph these things.  Thanks, Rick. There we go. So I get to try and defend myself against Ian. So why do you use a biologic augment for massive and revision tears?  It's pure collagen to add biology, create tendon-like tissue, easy insertion. It has a proven track record. It does improve rotator cuff healing, and it has a high safety profile.  So Ian's going to argue. Ian just argued that you don't need to augment these tears. And Ian's wrong. And so Ian's brilliant. You know, he's a snappy dresser. He's stylish.  He's fit. He's a master at the proteome. But there's a darker side to Ian Lowe. Don't be fooled by all of Ian's semantics.  Not many people know that Ian has competed as a professional bodybuilder, and he's won at high levels. And he takes his prizes, and he takes his money,  and he uses this to buy biologic implants on the dark market. Ian uses these implants. And then he throws parties, and he goes wild. He makes it rain with biologic implants.  And he converts our trusted colleagues in the market, like John Bravman and Fay Leung. Ian's a strong believer in nutrition supplements,  but don't necessarily ask him about how he gets extra protein in his diet, because you might not want to know. He publishes on this. So he's got publishes on this exact implant.  I use it every time by Ian Lowe. He presents on this. So he presents on biologic augmentation at international meetings, and he smuggles these implants into Latin America.  And when he doesn't get to use it, he gets mad. So let's talk about why we do use it. This is actually a pure collagen implant. So it gets called a xenograft, but it's not.  It comes from a cow Achilles tendon, and it's biologically engineered in a way to remove the source DNA and protein.  So you get pure collagen fibrils that are then constructed into this implant. We've seen from biopsy studies, like Steve Arnosky and Camacho Charcan,  that when you biopsy this at six months, it creates tendon-like tissue, and the implant goes away. So it actually creates highly structured, organized collagen fibrils.  It does have an easy insertion. So as Ian mentioned, you can bring this in beach chair, lateral. You can bring it in from lateral, anterior, posterior.  You can place it directly over your repair. You can put this implant wherever you want it. It secures fast and easily with absorbable PLA staples that'll go away.  Very easy insertion. It shows it increases tendon thickness by two millimeters. The outcomes are durable. So Des Bakker's work at five years shows that patient-reported outcomes  and pain relief is maintained at five years. It works in partial tears. It works in full tears. It works in massive tears. So this was our study at Tulane that Ian brought up.  So he's calling Buddy Savoie a liar because all of these folks had an MRI at 12 months that showed the tendon had healed 96% of the time.  So I would not call Buddy Savoie a liar, but Ian Lowe just did. And this is the other study that he mentioned. And so a prospective randomized study looking at full thickness tears  all got a double row repair, half got an augment, half did not. The ones that got an augment had a one-third re-tear rate at 12 months and 24 months. Now, Ian is correct.  This was one to four centimeter tears. But even in the large four centimeter tears, it helped the tendon heal and it protected the muscle tendon junction.  The key with this is you need a repairable tendon. So Ian's a fantastic arthroscopist, but if he's gonna pick the wrong surgery  for an irreparable tear, like he showed you a second ago, it's not a panacea. If you can't get healthy tendon back to bone, if muscle's not healthy, like JT said,  it's not gonna work. So the first case he showed you with a retracted tear that barely comes back over, we know that needs something other than this because it's not gonna heal.  Finally, adding that biologic implant results in increased ASCS scores, increased constant scores, better pain scores, and it could potentially get you back to work faster.  One big issue is cost. And so Lou McIntyre even did this cost analysis and he showed that this implant, augmenting massive tears can decrease  the societal burden of rotator cuff disease because it can decrease your retear rate. So it can help be effective cost-wise too. So these are the patients you think about it for.  We know higher age, diabetes, smoking, high cholesterol, big tears, bad tendon, atrophy, retraction. These are the ones that you need something else. You need a repairable tendon  and you can repair this any way that you like. So in this case, we're gonna do our marrow stimulation. We do a double row repair because we have enough tendon to do so.  And then as Steve Snyder would say, you finish the operation and you put a patch on top.  So I would argue that if you have a repairable tear, massive or revision, you should use a biologic implant. So it's easy, it's collagen, it helps improve healing rates,  it can speed up your recovery, it's effective, it improves outcomes, and it's durable. So try it, you will like it just like Ian Lowe.  Thank you.  Appreciate it. Thank you. All right, thank you. Can I ask how many of the audience have had experience with augmentation? With your cups, so everybody.  And so out there, I think in the exhibit area, you're seeing a lot of people showing you some new augmentation techniques that are pretty cool. So you should look at that.  And the whole concept of augmentation, I think, is an interesting one as far as decision making again. And so I'm a little torn because I'm an old school augmentation,  which means it's anchored medial and lateral to the actual repair and a protection repair. This is, to me, not a true augmentation.  This is more of a biologic supplement using the scaffold because it has no strength at time zero. But that said, augmentation is thrown around.  I mean, you could make the argument that doxycycline and keeping your MMP level down may be an augmentation in helping the healing environment, the enthesis healing.  So with that, this is 59-year-old with a failed cuff repair, retracted atrophic, grade two cutalier. We look at the RoHS score, and I call it RoHS versus RoHE.  I like the RoHS score, and it's right at seven. And as you know, the algorithms are less than seven, no augment, more than seven augment, kind of as a level five data.  But this is seven right in the middle. You can see on the right, it's retracted, it's beat up, not healthy looking cuff.  And we look, and here you see delaminated, it's retracted, an old suture, not terribly retracted. And we can kind of put some traction sutures, we're able to reduce this.  But you know, it's beat up. So I'm gonna ask how many of you in the audience would augment this with something? Show of hands.  How many would not augment it if you get it down, let's say a single row or even a double row, how many would just say that should be good enough for this?  How about on the panel, augment?  Yeah, but I think for something like this, I would want something that's structural. I mean, failing in continuity happens all the time,  even in small tears, massive tears, it's happening rapidly. I'd need something that can actually provide some structural support. And there are other grafts in the market  and that may be something I would use for something like this versus a very thin, purely biologic graft. Yeah, and I think in this one, we've seen that the biceps is good, the SCR,  the biceps transposition would be a good idea as well to help supplement that. Okay, Ian, what would you do for what you're seeing here? No additional data, just looking at that.  I would augment it and then I would look at the tissue. If the tissue looks bad, I agree with, okay,  I might use a dermal allograft or something more structural rather than a pure biologic. Okay, all right. Especially in the revision situation. Yeah, exactly.  So we'll just show what we did here. So basically, we're able to get a single row down  and we microfracture footprint and then we basically drop a dermal allograft in and we drop the graft in again. I really want something above and below  that protects my repair and this is a true augmentation. This is actually gonna protect my repair and this is pre-op and here,  the reason I get scans pretty early, people tell you don't get a scan after a cuff repair because I don't want them to go through a long rehab if it fell apart. And so here we see.  But if you're gonna get a scan, get it early. Well, early here. Yeah, yeah. 24 hours. Yes.  I like the recovery room scan. That's my favorite.  Hey Rick, the only thing regarding, do you always do MRIs? The only argument, I guess, would be getting a lot of post-op MRIs is that outcomes really do not correlate  with the Rohe scores. No, so the reason I get this in these cases when I do a augmentation is that I'm worried about the integrity of my repair and if I get one here at eight weeks  and it is not, it's coming apart, I'm not gonna put them through the long rehab. I'm talking about what we're gonna do next. That's why I do this.  I don't routinely get everybody that I do a repair on but the augments, when I'm really worried about will my repair hold up? I wanna know, they wanna know and so I do this  but that's the reason why it's at eight weeks. What do we do next if it failed? Even if they're doing great? Even if they're doing great, we just do that.  As you know, they don't do great at eight weeks. They're still whining as they should be but I think it's, for me, I just hate to put people  through stuff they don't need to go through if we can avoid it. I would love to hear that conversation you have with these patients. In terms of?  When it's failing, that must be just like an interesting conversation. That would be like every. No, in my case, it's theoretical only just so you know that.  So you found that eight weeks is a sweet spot, is it? So Rick, you do the same MRI scan for rotation in eight weeks?  This is a file photo. We have to, so let me ask, when does a cuff fail? Let's say without augmentation, if it's gonna fail, it fails relatively early, right?  So I think at eight weeks, you have a pretty good idea whether it's gonna hold up or not. And so I, we have a number of these cases and I'll just tell you, I'm really impressed  with these augmentation type cases when you're really worried. I think you sleep better at night if you do a good augmentation. And I like to use something mechanical.  And now there's some out there that are mechanical plus in-growth. They're just the in-growth and they're those that are just mechanical like dermal allograft.  But I think it could be a good choice. That's so interesting. So I think we have a couple of minutes left. We covered four, I think, pretty important topics  and I hope we've given you a little insight as to how hard it is to make decisions. As you can see, we struggle a bit making decisions  and I think all of you in the audience struggle and I think it's natural. So with that, I'd like to open to some Q&A. If anyone has any questions regarding dilemmas  you're facing in your office or in the operating room and maybe someone on the panel can help you with some decision-making. Anyone? Don't be shy.  By the way, Joe, congratulations. Thank you very much. Please. So Joe's our new second vice president. Congratulations, Joe, well-deserved. Thank you.  So the elephant in the room, what did you say? I can be myself now. No, no, no, heaven forbid. Go ahead. No, no, certainly not. No, we're joking. Go ahead, Joe. Look out.  So the elephant in the room for me is at my ASC in the Medicare patient where I don't get reimbursed for this stuff. You know, I have this huge guilt trip  that I have a double standard that in my private pay patient, we have carve-outs,  I can augment these, you know, I feel great.  So the dilemma is how does everybody deal with the real dilemma, elephant in the room, of when you can't get reimbursed for these grafts,  you know, what do you do, what are you thinking?  I assume that everyone's got the hospital versus their own ASC. So are you just dragging these to the hospital or are you just abiding the cost? Kevin? Yeah, I only go to an ASC.  And so basically, we're a joint venture, so it sort of matters. But to be honest with you, for the most part,  your partners will give you a hard time if you're putting in a graft on everybody, there's no question.  I try to sort of pick and choose who I'll do a graft on, but honestly, I also don't think about it, Joe. I mean, if somebody I think needs it, then I do it,  but I don't do it on everybody. I know a lot of people put grafts in almost all their repairs. Other people put, we actually did a study on this  and published the disparity between the people, some people put in a graft on everybody and some people use no grafts. I use a graft in less than probably 15% of my patients.  And just say, listen, you're profiting on that other 85% of cases, you have to suck it up on these 15%, sorry, so. All right. Professor Gettleman, you're a businessman.  Yeah, so I think if their biceps is intact on that patient,  then I don't have a conversation about a graft. If the biceps is absent, then I'm gonna have the conversation about a graft and then we have the decision to make  because I won't do this operation in the hospital. It's too painful for me and it's not worth the time. So I'll actually send the patient to one of my partners  if they wanna do it at the hospital. And so we'll eat the cost like Kevin says.  You know, there's patients who have insurance that gets denied and you can do four peer to peers and it still gets denied. And those patients I have a cash augmentation,  they'll pay cash for it. You know, he's mentioned the biceps. What he's saying is that he'll use, he'll create the anterior cable and he'll basically tinned it right at the entrance  into the bicep of the groove and then use that as the anterior leading edge of the cuff and bring the rest of the cuff to it. So that's what he's saying, the biceps is there.  And Larry Field has a nice study, bio-SCR augmentation for full thickness massive tear repairs, showing that the results are pretty impressive and it's in situ.  And for Larry, he doesn't care what the biceps looks like, which is kind of interesting. And he's only had one re-rupture in his series and he's been very happy with that collagen.  And that biceps, because JT's got his smash technique using the proximal biceps, which is excised. You put in a device, it smashes, it makes it into a graft.  Now it's structural, it's biologic,  the cells are viable. And I think JT has some pretty interesting data showing that as a very nice alternative in terms of cost for putting in something  that's structural, in growth, and it's free. So I think your data's coming out pretty soon, isn't it JT? Yep. Yeah, so you call it the smash technique  or some like smash Nana, all this stuff. I mean, you must have a lot of free time on your hands. Jesus Christ. I'm trying to be like those guys.  As many algorithm initials as I can get. All right. Any other questions from the audience regarding this? Rick? Yes. I'm sorry, please. For the anterior cable reconstruction,  I keep going back and forth. Can I ask you to stand and be as loud as you can? There's a microphone here too, so the people on this end may not hear you.  So why don't you march up here if you don't mind so everyone can hear you in the room.  Just for the anterior cable reconstruction, what are people doing distally? Is everyone tenotomizing and then doing a distal tenotomy? Is everyone just rerouting, leaving it distal?  I've seen both. I've done both. Curious what the experts are doing. Reroute it and leave it. Larry Field has shown in his study, reroutes it, leaves it.  They don't get biceps pain and they don't rupture. Which is shocking. I fix it. I do a tenodesis. You do? Yeah. I just can't get there. I know what the data says. I leave it.  I just leave it in place and blah, blah, blah. It's certainly faster. But no, when you leave it, you still fill the tenodesis? It's a tenodesis. You're tenodesing. No, no.  You are reattaching it in situ. I do, and I write it out. It's a tenodesis in situ. I leave it attached distally. Whether I do an anterior cable or I move it over.  So I'll make that determination based on what I'm trying to do. If I can't fill the defect, then I'm gonna take it out of the groove  and move it laterally and move it more posteriorly. But I'll leave it anteriorly in the groove, tenodesing it in the groove as a anterior cable.  Steve Snyder, for five years before he retired, did every tenodesis and left it intact. Didn't take any of it. So a couple of pieces. One is I take down the transverse ligament.  Just in case anything is gonna be trapped in there, I'll take that down. And the other is when you tie your knots down, external rotate, abduct the arm when you anchor.  Because if you don't, you're gonna put undue tension on that biceps tenodesis. So external rotate, abduct, before you tie it down. That'll help you a little bit, I think.  Stay out of trouble. I'm not so sure about the anchor it in that standard position without putting too much tension on that biceps in situ. How is it not a pain generator?  It's just amazing to me, but clearly it is. I think the issue is the biceps motion in the groove with flexion. I don't think it has to do with the generation of the biceps.  I think once you lock it down, whether you're tenodesing it in situ, leaving it intact or not, you stop the motion. And once you stop the motion, you stop the pain.  That's my theory, too. Tenosynovitis around the biceps in the groove. You're getting it out of the groove. It's not moving anymore. I don't know.  But the important thing, like Rick said, you gotta release it all the way down. Because if you're gonna mobilize it, if you leave it kinked, that's not a great thing.  Well, clearly people don't like our answers. Please, go ahead.  Sure. Very good morning to all of you. While we were discussing about the arthroscopic DTA versus lethargy, so we were concluding that  if you've got a poor labrum and tissue quality, better to do a lethargy. So is there any preoperative criteria where you can decide that this is going to be a case  where there's going to be a poor quality of tissue? So the question has to do with how do you make a decision preoperative regarding the quality of the tissue?  And do you do a lethargy to use a sling effect? I'm not sure that you can, other than the history is very helpful. Occasionally, your MR studies can be helpful.  But if someone has failed two or three operations, I'm very suspicious about the tissue. First, it's sometimes stiff and maybe looks thicker because it's stiff,  but it's just not healthy tissue. So I don't know that I can do anything preoperative other than a high index of suspicion, but I think I tend to look at the tissue  at the time of surgery in conjunction with their history to get an idea, is their tissue compromised? Do you guys have any tricks? I asked Ivan Wong the exact same question.  And I said, when do you use AAGR and when do you use lethargy? And early on, I think if he thought they had poor quality tissue of their labrum and capsule, he'd do a lethargy.  Now he's 100% DTA. So. I don't think there's any data that says that poor tissue makes lateral J work better necessarily. It makes sense, so why not, right?  But I don't think there's any data that shows that. If you're doing arthroscopic DT and not able to do the labrum repair, is it fine? You can keep it inter-articular or?  That's a great question because the Marota study is basically just a J graft and people like Laurent take out the labrum. So I think you make the argument,  you lay the bone block in, you sort of extend the porch  and you go home and you don't even have to do that. Now I bring it down and I know that that Bankart repair isn't going to survive. It's a controlled failure because if you go back  and look at some of these cases, you'll see it sort of stretched out even though it's there. But I don't know how important that is. Is it actually restraint? I don't know.  You know, I would pose a little bit different. I think that that repair helps with healing because I think it's restricting fluid coming out of the joint.  I don't think it has anything to do with stability. I think that's why he's getting better healing is because you're sealing that so it's no longer exposed to the joint fluid.  Okay, all right. Well, interesting concept. Yes. My question is again about the biceps antidegradable augmentation. And in site of fixation with Schneider did  and the antidegradable augmentation are two different points, isn't it? The antidegradable augmentation is attachment to the antidepartmental data duperosity.  So I would like to ask the panel, what is the cutoff? How much can you transpose without detaching it distally? Like for an SCR, we have to transpose. So what is the cutoff?  Like five millimeters, eight millimeters? That's a great question. Larry kind of pulled it over pretty far a long ways. That kind of always worries me.  That's why I started taking down the transverse ligament. How far, I tend to bring mine out of the groove slightly and go slightly kind of posterior to the groove.  How do you guys feel about that? How far can you go medializing that bicep so that you get the rest of the cuff to it before you start to worry  that you've put too much stress on it? I pull the infraspinatus over as far as I can. Do my releases, pull the infra over where the infra ends, that's where I put my biceps.  I'm the opposite. I don't want to put any tension on that infra because it's trying to die anyway. So that's why I'll team a decent distally  and then I can swing the biceps wherever it needs to be to meet the infra where he lives. We don't want to bring the infra to the biceps. That's the problem.  We'd rather bring that biceps to the infra and then your retail rates, I think, are gonna be lower. All right. My question is, how much can you posteriorly move the biceps?  I don't think we have an answer for you. I don't think we really know that. I will tell you that Larry Field, who's published on this,  he brings it over probably halfway under the tuberosity and he's citing good results. And obviously, the more you can bring it over,  the more you can bring the rest of your cuff up to it. So there's an advantage there, but I don't have a good answer for you biomechanically  as to how far before you are in big trouble. But I think you can probably go at least, according to Larry, halfway across the tuberosity. Yeah. One last. Go ahead.  You know, for the bicep, if it's repairable but it's like poor tissue, I typically would just leave it anteriorly and have an anterior cable reconstruction.  It's if I cannot repair it and I'm trying to use it in SCR there, bring it back, usually about a few millimeters. Super. Thank you. One last question.  I know you all have to get back to the meeting, so please. Yeah, just your experience and if you haven't experienced instability with the DAS, the dynamic anterior stabilization,  and where in your algorithm would you fit that procedure?  The dynamic anterior stabilization is taking the biceps tendon, the proximal portion, bring it through the subscap and then attach it to the glenoid neck.  So it's kind of a variation of a soft tissue, latter J in a sense, holding down part of the subscap. Does anyone here, JT, any experience with that? And can you share it with us?  Yeah, I've normally used the DAS in settings where I've got chronic subscap insufficiency and a patient whose sublux is anteriorly with that,  I'll do an anterior capsule reconstruction like an SCR but in the front. But I want something dynamic there and I'll put a DAS through that. So that's my best indication for it  because I have a live muscle transfer that will dynamically stabilize the front. The reason I haven't done it a lot in the other situations and we have other options,  I'm trying to replace bone or everything else. But I will say that in patients who are failed, like I've had a few failed ETAs with massive resorption  and I'm going back in for a third revision, then I think a DAS for me has been a bailout. And honestly, it's been surprising to me. Right, I mean, that's your experience too, right?  Yeah. It's a little shocking because it's fairly simple. I don't put it through a big tunnel as it's been described. I just do an onlay on the front, maybe it'd be the same.  But right, is that your experience? Yeah, that was why I was asking because I think it has shown us great rates of stability  to the joint and it is easy and quick. It's a brilliant concept, it's so simple. I'm honestly surprised that nobody, maybe 20 years ago, didn't start doing this  because it might work. We need to study it. Thibault Lafosse uses it as a tool in our algorithm, just like you guys are saying. So I think when they're hyperlaxed, he'll add it.  Or if it's a failed instability with really no bone loss. Yeah. You know, with that, first I want to thank the faculty. I mean, I just can't think of one more wonderful,  more thoughtful group of individuals. So thank you to the faculty. Thank you all for attending. Enjoy the rest of the meeting, everybody. Thank you. Thank you. Nice job.

Video Summary

The video transcript is from a conference titled "The Great Debates," focusing on four critical topics in shoulder surgery. The panel, consisting of esteemed faculty and shoulder surgeons, engage in robust debates about these topics, presenting various cases and arguments. The topics discussed include Remplissage for Bankart lesions, distal tibial allograft (DTA) versus Latarjet procedure for glenoid bone loss, use of superior capsular reconstruction (SCR) in rotator cuff tears, and the necessity of augmentation in rotator cuff repairs.<br /><br />Dr. Anna Quincy argues that Remplissage is vital in Bankart repairs to reduce recurrence and failure, especially in high-risk cases. Opponent Jennifer Smith counters that Remplissage should be selective, as not every patient benefits from its application, particularly when the tear is non-engaging or athletes need preserving their range of motion.<br /><br />Discussions on the DTA versus Latarjet focus on technicalities, with Dr. Saccone advocating for Latarjet due to complications with DTA, whereas Mark Gettleman highlights DTA's safety and effectiveness.<br /><br />JT Tokish and Kevin Bonner deliberate on SCR, with Bonner criticizing SCR's high non-healing rate, while Tokish emphasizes its benefits for non-functional, massive tears without arthritis.<br /><br />Finally, Ian Lowe and Michael O'Brien debate augmentation in rotator cuff repair, with O'Brien endorsing biologic augmentation in revisions and massive tears to enhance healing and outcomes.<br /><br />The session concludes with an interactive Q&A, allowing audience members to engage with the panel on real-world challenges in shoulder surgery, including reimbursement issues and procedural nuances.

Asset Caption

Keywords

shoulder surgery

Remplissage

Bankart lesions

distal tibial allograft

Latarjet procedure

glenoid bone loss

superior capsular reconstruction

rotator cuff tears

augmentation

biologic augmentation

surgical debates

shoulder surgeons