Hi, good morning everybody Really, thank you guys for being here and seven o'clock on Saturday. These are the real dedicated learners here This session's on non-arthroplasty options for massive cuff tears And as we think everyone here knows this is a topic of wide controversy and a lot of to talk about I first Our disclosure on what I want to really thank our faculty here We really have a great faculty Sarah Edwards from San Francisco Rob Hartzler San Antonio Eric Wagner from Atlanta and then Ivan Wong from Halifax and Just to kind of set the stage, so we're all talking about the same thing We know that irreparable cuff tears have many definitions, but most of us would say Intraoperatively are unable to repair to the footprint and if you're like me you look at these options, and you start getting a headache And so you know there's a big sort of wide spectrum of The options that are available in this difficult scenario, and then there's some newer options We'll talk about this as well the tuberoplasty What's an anterior cable reconstruction the biceps and then Ivan's going to tell you how to do a bridge allograft successfully? And so this is the general outline will first go through just debridement alone And partial cuff tear then we'll talk about tendon transfers Then Sarah's going to talk to talk to us about the biceps SCR and anterior cable reconstruction Ivan's going to talk to you about the bridge allograft Reconstruction and then lastly Rob's going to talk about the subacromial balloon spacer And then we'll hopefully have a little bit of time to talk about one or two cases so we can illustrate sort of the The complexities of the situation so I'm going to talk to you first about arthroscopic debridement and just bicep surgery Maybe partial repair and why this might this should still enter your thought process, and it still may be cost-effective So some of these slides are repeated from the talk I gave yesterday But you know we had to talk about sort of whether we're talking about the same thing when we're looking at this cohort of patients Is it true pseudo paralysis? I think all of us understand what this looks like when you really see it enter super escape I'm pretty sure whatever arthritic changes this person has they're not improving with anything other than a reverse How about just isolated pain so you have just pain, but you have well-preserved function you have good function Maybe some minor arthritic changes what options are available Well, I would really argue that you could do anything and and these patients will probably do well In fact if you look at some of these studies. This is a consensus statement from ASCS members Pretty much all treatment options do better than physical therapy with no difference between groups And then this current concepts from the Mayo Clinic and some of our friends there You look at the grade of recommendation for all of these is C Right neither for nor against which means they either all work, or they all work Not so good a partner my partner, and I looked at this through pit at three with three thousand Shoulders and that turns out that if you kind of compare I think you lump everything together to Bremen actually had the best outcomes in terms of range of motion and pain scores Although it did have the highest conversion to a reverse and so I think the question We should be asking when we look at all of these options from a cost and from a effectiveness standpoint is how do they compare to Debris men and partial cuff and that should still be sort of the gold standard what we compare everything to we know about the The loss of the rotator cable and the force couple from dr. Burkhardt years ago, and so this concept of margin conversions is something that can be That can be tried if you if you have an irreparable cuff And what it is is you bring the two edges together and you do a partial repair try to restore the cable You can do this when surgical repair is not possible like poor tissue quality tendon loss severe attraction or increased tension Well, what about what are the pros here the pros are the relatively fast procedure? You actually get good patient report outcomes relatively cheap get pain relief cons Maybe high rate of retair maybe for aggressive cuff arthropathy a lack of complete footprint coverage now What's the literature supports this well if you combine? Debris mint with some form of decompression or tuber plasty or something else by system on me. You can actually get very good Very good outcomes if you combine this with a partial Repair or compare this just a subchrome decompression partial repairs may do slightly better despite relatively high failure rates and Both cultures are subchrome decompression, but similar satisfaction between just the breeding it and doing a partial repair These are actually you know midterm follow-ups or seven years four years These are older studies, but partial repairs actually have very well-maintained outcomes over a midterm follow-up What about just cutting the biceps the Walsh and ballo have described as long ago? Maybe everything we do is really too. Fancy just cut the biceps get rid of the pain generator and move on So these pictures are what I consider to be tricky right you have a mixed picture of pain functional loss The factors I consider when I'm I'm picking a treatment option include like age Arthritis goal of surgery durability the procedure and risk tolerance And I'm often finding myself trying to exclude a reverse replacement in this population and the ones that I think are very good for reverse One they have to be very comfortable with the risks of reverse To advance age or cuff arthroplasty maybe regardless of what their function is and They need to have a desire for a durable predictable outcome where there's just pain relief functional restoration or both I would be very very careful if the patient has isolated external rotation problem That's probably not getting better with reverse or some of the treatment options that we're going to talk about I'm going to talk a little bit about SCR I know it's gone falling out a little bit out of favor and maybe because of studies like this from Rush that demonstrate that you can get good outcomes, but the graft failure rate is pretty high whether for allograph or Autograph now we've done some studies looking at kinematics to see whether or not SCR Really does anything for the kinematics in vivo, and this is our biplane Apparatus we looked at some ten patients who underwent pre and post-op in vivo testing Following SCR, and we were thinking that the kinematics would really change significantly But to our surprise really none of the kinematics changed post-operatively and despite relatively high healing rates the Outcomes had nothing to do with kinematics or graft healing that all the patients actually improved significantly beyond MCID Despite that maybe it wasn't doing what the cadaveric studies showed The other issue is that these grafts actually stretch quite a bit some beyond sort of failure strains in vivo And so you really wonder how does an SCR work if it's not affecting kinematics? And so we had postulated after these studies or these surprising studies And maybe it's more of a pain relieving type spacer And so then we will you know that led to the idea of well is tuberoplast is this you know tuberoplast are going to do The same thing and maybe why a subacrylamide balloon spacer is effective now if you compare SCR versus just margin convergence there probably is one cohort that benefits from SCR, and it's the patient Who has pseudoparesis so elevation less than 90 degrees that patient in our study here Demonstrated more significant improvement, and so if you have well-preserved motion you probably could just do margin convergence if you had Elevation less than 90 margin convert or SCR seem to be favorable and these are also supported by other sites like from dr. Millett and with the veil group demonstrating that if you have that their rotator cuff repair group actually did better In the long run if you could repair the rotator cuff rather than an SCR Maybe what we should talk about is cost-effectiveness this study for Mayo Clinic looked at three different Surgeries SCR actually the most expensive surgery compared to reverse in tendon transfer And how is it compared to tendon transfer? I'll have obviously Eric will talk a little bit more about this, but actually if you compare head-to-head in some studies Partial repair versus lat tendon transfer partial repair actually did better in this study There's probably a lack of studies looking at partial repair versus lower trap transfers but if you look at just comparisons of lower trap and Lat Dorsey lower trap seems to be a little bit better. Just going to graze on a few slides on subacromial balloon spacer and There's some in vivo study or in vitro studies that support it from a biomechanical standpoint and But the question is you know a lot of times If you do an in vivo study like the one that we would did with SCR we might not find the exact same thing Now I think most of us know this study Published in JBJS looking at balloon spacer versus partial repair And this was a randomized controlled trial demonstrating a non inferiority of the balloon And I'm sure Rob will talk about this a little bit more but In the very least it looks like it could be a viable treatment in comparison to partial repair But here's the other thing this is a other study published in Lancet and I only bring this up because the Lancet impact factor has 79 and all the orthopedic literature that we read have impact factors of six and You know if you look at balloon versus debridement in this cohort is a double blind multi-center randomized control trial Actually supported debridement rather than subacroma balloon spacer now. I I'm sure Rob will tell you that this was if you Carefully select your patients you may not get this outcome, but nonetheless this is also out there So here are my couple conclusions here I think that if you have full motion full motion and pain is your primary complaint or isolated pain Don't forget about debridement partial repair and modular convergence. It works It's cost-effective if you have really a true pseudoparalysis, that's probably not improving anything with the reverse It's the mixed bag of pain and functional loss that I think you need to consider with minimal arthritis and pseudoparesis Maybe you can consider things like biceps ACR bridge allograft SCR for a younger patient balloon for either a young or older patient an older patient with or without advanced arthritis And they want one procedure. I would consider reverse if external rotation is your main problem You're probably not getting that back with anything other than attendance transfer And I think we need to ask ourselves our newer options more cost-effective than partial repair And I definitely think that higher quality Comparative studies are needed so that we can really determine the ideal indication. So we're comparing apples to apples and oranges to oranges All right. Thanks very much Great um, so my name is Eric Wagner. I'm So I'm gonna talk a little bit about 10 transfer when to consider it Go into some technical details of how to actually do it potentially that with a biceps SCR and some other Hopefully thought-provoking considerations, so disclosures are not relevant to this presentation One thing I should disclose though is when I'm defining and Albert did a nice job of Defining what air repair ability means when I'm defining it, although there's many different considerations of what is an air repairable cuff This is something that I do make a decision on preoperatively as I'm hoping for a to define or to at least And you'll see some some data to back this but I'm trying to assess the what I think the cuff is before I get there because if we're looking at functional repair ability and and what ultimately I think the functional outcome will be after the And not it might be able to physically repair it during surgery And I'll show you what I mean by this and some clarifications for this So we're gonna mainly talk about posterior superior cuff tears Anti superior is a sort of a whole different type of topic, but definitely less common. So from a posterior superior When when you're looking at your treatment algorithm or when we evaluate patients, we're really evaluating What's the force couple and a really important part of this force couple is the infraspinatus? So when you look at the balance of the shoulder and you look at the main function of the rotator cuff It's really this balance that it creates allowing the shoulder to do a variety of different things When you don't have an infraspinatus you really have Two or when you don't have a posterior aspect of the force couple There's really two different ten transfers that you can potentially use to rebalance this the latissimus and the lower trapezius You've probably heard a fair amount about this but some of the the main reasons why at least in my mind I prefer the lower trapezius as a As a ten transfer over the latissimus is joy and I study showing about 35% of latissimus is do not retrain So it's an 80 doctor internal rotator You're trying to turn it into an abductor and external rotator And when you look at the actual line of pull of the infraspinatus So let's assume this is quite different than the lower trapezius So in general for me and in general for this talk, we're going to be talking just about the lower trapezius transfer So we use this to rebalance the posterior aspect of this force couple It's an in phase and inline transfer meaning that it it contracts when you actually rotate it contracts when you abduct and as you can See it sort of maintains your scapula humor rhythm that I'll talk a little bit more about in a second So there's a variety of studies Boston I was looking at to help Boston with his initial openness series now It's become arthroscopic assisted and I think most of the things you'll hear about are based on this arthroscopic Assistive technique and variations off of it in general. It does very well clinically We've shown it's a faster recovery curve than latissimus. There's a faster recovery curve than the SCR and when you compare it to When when you look at the scapular rhythm, so this is your normal scapular rhythm as you can see the glenohumeral versus the scapula thoracic motion it's about a the normal motions about 2.5 to 3 for your scapular rhythm meaning you divide your glenohumeral over your scapula thoracic When you look at massive cuff, you can see that the drops precipitously because there's a tremendous amount of scapular compensation that's happening but when you look at the lower trapezius results versus the reversal to arthroplasty results You can see that the lower trapezius really mimics a normal scapular rhythm And this is different than you do with something like a reverse So this is a non anatomic procedure produces sort of somewhat of an anatomic motion capacity of the scapular rhythm So here's a case presentation 56 year old very active guy loves golf tennis. I'm from Atlanta. Everybody wants to get back to golf I feel like that's the main reason I do surgery is to get people back to golf The you can see he's pretty limited. He had a prior rotator cuff repair, but otherwise Otherwise, he has preserved active external rotation. Maybe a little bit of external rotation lags on but he has weakness And he has and limitations and you can see with the scapular rhythm. He has some limitations in his in his motion He has a posterior superior retracted cuff tear. You can see it's retracted small tendon length. You can see there is a Sub scapular tear as well and then you can see that there's some fat infiltration in the Supersanity emphasis, but relatively preserved Terry's minor So what do you do that for this patient? Well, there's a variety different options we decided to do a lower trapezius transfer given the fat infiltration and given the imbalance in the force couple at least in my mind And a couple of technical pearls on this So one when you when you bury your initial anchors on the load because you're trying to recreate the upper infraspinatus So I'm putting my anchors at the anterior aspect of the groove the ones at least that are connected to the to the crack house Another technical pearl after you do the harvest the harvest. I'll show you in a second off the medial scapular spine. You'll transfer this graft into the joint I like to preload these anchors into two different portals makes the arthroscopic part a little bit easier and then after placing a total For anchors to really compress down the graft you'll do bring the arm an extra rotation I do a pulver taff weave and really tension it in place This is kind of showing the pre-loading of the anchors prior to placing the graft allows the arthroscopic Visualization to be a little bit easier and a little bit less fuzzy And then this I'll show you in a second is a biceps SCR. So you're adding the biceps in patients that have subscapularis Pathology as well I like to add in the biceps helps at least in my mind with that the anterior superior escape that patients potentially could get So this is showing you the technique. It's a relatively quick, but this is your your incision so you can kind of feel that axilla you can kind of feel where the Large piece is coming on the medial board of the scapula It's really important to excise fat first especially if you live in Georgia and you have a lot of people who like biscuits and southern cooking the You'll find the inferior border as soon as you excise some of that back fat You can follow it all the way to the scapular spine and then you just take it right off the scapular spine. It's not a It's a it's not a it's not a hard muscle to find It's the only muscle back here besides the the atrophic infraspinatus and then and then you're once you've released it from the spine You don't have to dissect medially don't have to mess with the pedicle. You just sort of Start crack calling its tendon. So this is the tendon that we've harvested. This is the Crack out to sort of create this bullseye for the later later pulvotaf weave and you can see the excursion that you're able to get So these are the kind of standard arthroscopic portals pretty standard portals that you use for that you'd use for a rotator cuff repair So I'm going to show you the first part preparing for the biceps SCR so this is just tagging the biceps SCR right at the right tagging the biceps right at the level of the joint and wrapping the tendon around wrapping the suture around a couple times and then you'll see I'll bring it back through a Second time to sort of create this This kind of construct that will later allow me to bury it with one of the anchors I then expose the biceps lower in the groove I will tag this as well and once again wrap it wrap the suture a couple times around to create this sort of construct that then allows me to perform a tinnitus or Placing it back through then I like I do like to detach the biceps so I will do the tinnitus of the of the more proximal part and then I mean the distal part and then I'll Bury the proximal parts into the biceps cable with the tendon transfer I do do partial cuff repairs on every single patient, even if there's advanced infraspinatus fat infiltration I still believe that you can augment the the power of the lower trapezius by doing a partial cuff repair So you can see here basically I'm placing two sort of ripstop stitches and then I'm doing an inverted horizontal mattress into this anchor that allows you to Do a knotless repair and then I'll bring those two lateral Stitches into one of the anchors of the lower trapezius as you can kind of see here So then I prefer the transfer Before I had the big graft in the joint. I'll sort of mark where I want to put my four anchors I put these two cannulas in. I think this is really important, because as I mentioned, I will bring the sutures on the crack out of the graft into each one of those prior to actually bringing the graft in the joint. I use a long hip arthroscopic grasper, bringing this Achilles tendon into the joint, and you can see preloading the two cannulas prior to replacing them. It just makes it easier once that big graft gets in the joint, it makes it easier to see. So this anterior anchor, I'm gonna put not only the graft stitches, but also the stitch from the biceps cable reconstruction. And then in the more lateral anchor, I'm going to just put the crack out stitch. And then you can see I preloaded these other two stitches. They're about two centimeters back. These are just to add some extra compression, so I do one laterally, and then I take the partial cuff repair stitches, as well as the other more medial preloaded stitch, and I bury this one medially. So it creates sort of like a box-like effect, pushing down the actual graft itself, and you can see the biceps cable reconstruction. You can see the graft laying down. Underneath it, you can see the partial infrasteneus repair. So it's creating a really nice, I think, compressive effect of the graft, of the partial rotator cuff repair, and of the biceps cable. In this case, I didn't show the subscapularis repair. We did the subscapularis repair first. So then you're gonna split the graft, and then you do a pull-for-taff weave. So you really wanna over-tension this. As far medial as you can, I mean, as far lateral as you can on the graft, and as far medial as you can on the trapezius, you're gonna really tension it down. You cannot put too much tension on this. The arm is already in external rotation abduction at this point. And then I'm placing multiple figure-eight stitches, and then I'm bringing the other end of the graft over the top to create sort of like a sandwich, as you can kinda see here. So once again, you cannot over-tension this. So one piece of advice I can give is the more tension, the better. It's an allograft. It will stretch out. I do keep the patient in external rotation afterwards, so I don't worry so much about the over-tensioning and the tearing effect. And you can see our ultimate construct of the graft into the lower trapezius. So I use this Donjoy Quadrant. It allows me to dial in external rotation, and there's a little bit more, people are a little bit more compliant than some of the other things on the market. And then in general, this patient did pretty well. This is the patient with the subscapular repair with the biceps cable in addition to the lower trap. And you can see overall, he was great because you get back to normal function. You can't really tell which shoulder we operate on. Another case example, for those of you who were part of this session, I showed this one earlier, but this is a 61-year-old posterior superior tear. Got back with very little therapy. She's a farmer, doesn't really believe in modern medicine for the most part. And got back to pretty functional, maintained her function. And you can see her scapulohumor rhythm was maintained even at four years post-operatively. You can compare that to a reverse. So my experience has been there was a learning curve, and I'll show you, we've published on this in a second. But now it went from a procedure where my ACO was questioning why we were doing this procedure to now something that's pretty routine. I do have about a 10% failure rate when you look at people beyond two years of follow-up. I revised one to a reverse, two wanted actually revision tendon transfers. But this is the paper on the learning curve. It is about 14 cases from a surgical time standpoint. Not necessarily a complication standpoint, but it does take some time to decrease that. And this is our experience when we compare it to SCRs done at Emory. And this is across many different surgeons, although I'm the main one doing the lower trapezius. So when you look at the Gautelier classification of zero one, meaning good muscle, not a lot of fat. The SCRs actually did quite well. Their patient Barca measures, their failure rates were very good. When you look at those that have Gautelier of two, three, or four, higher fatty infiltration, the SCRs did poorly. Their failure rate was 59%. Their revision rate was 36%. Their patient Barca measures were really poor. And this is on converse to the lower trapezius transfer patients. You can see from a patient board outcome standpoint and from a failure and revision standpoint, the outcomes were quite good. And at least in my mind, this kind of reinforces this sort of algorithm that if there's good tendon muscle, you do a repair, rip softs, intervallis. If you have a tendon deficiency, a repair plus an augmentation, maybe biceps SCR, maybe an interposition graft. But then if you have muscle deficiency, you replace muscle with muscle. You do a lower trapezius transfer and then you repair what you can, maybe add a biceps SCR if you're worried about the anterior superior scape. So thank you very much. And please reach out to me if you all have questions. Thank you. It's getting so early today. Yes, sir. Don't you know who I am? Good morning. All right, so I'm tasked today with talking about superior capsular reconstruction with the bicep for massive rotator cuff tears. I have to be honest, when I was assigned this talk by my buddy Albert here, I thought, oh, people are gonna think this is so fringe and strange and weird. And then I get to the meeting here and everybody's talking about it. It's been on the main stage a lot. So yes, it's not so fringe anymore. So these are my disclosures, none relevant to today's talk. So guilty confession, I've traditionally been a bicep killer so I'm one of these people looking at Albert's talk when he showed that very frayed, ugly looking bicep, or I'm sorry, on Eric's, and I'm like, oh, I would do a tenodesis on that and not use it, but maybe that's incorrect. Maybe I should be using it more to help reconstruct these bad cuff tears. So again, what's exciting about this, finally something positive about the long-headed bicep. So how many people in here routinely do bicep tenodesis? Yeah, and feel that it's a pain generator. So I have also been in that camp. So I'm coming to you with that perspective. So I think the take-home point really, or one of the take-home points is just to think of this as a tool in our toolbox. It's not necessarily the newest thing on the market. We'll talk about that a little bit, but it's just one option of how we can help fix these. I also come from a perspective where I think too many arthroplasties are being done. We've really swung that pendulum where everybody's getting a reverse. And when I see a patient, a lot of this patient selection, you know, you can convince them to get a reverse. You know, oh, well, you get a big cuff tear, but when I see a patient who does not have arthritis, who doesn't have pseudoparalysis, who still has pretty good motion, is just presenting with pain, I really wanna preserve that joint. So I think these techniques are great. So I, again, come, and I think also practicing in Northern California, you know, 80 years old, patients are running, they're swimming, they're active. It's great to have that patient population. I used to practice in Chicago where if you were 80, you had one foot in the ground. In California, like, my 80-year-olds are active and thriving and, you know, and I wanna keep them that way. That's my goal. So this is just one case. 55-year-old female equestrian, fell off a horse a year ago, presented with worsening shoulder pain. She had limited range of motion on exam. Belly press was negative. Strength was a little limited, testing her subscap. And this is what her films look like. Fairly large to massive cuff tear. You can see, you know, decent muscle tissue there. Like, I look at that, that doesn't scare me. I see maybe, you know, grade two fat atrophy. And that is a patient. The other thing is looking at the considerations for treating this patient. So I also don't get afraid when I look at a bad MRI. All right, so you look at an MRI, it looks like a large cuff tear. But I think the tissue is different in everybody. So you can get in, sometimes that tissue's retracted, you're not gonna move it. But a lot of times it does move. Looking just from medial lateral, our coronal cuts on the MRI aren't necessarily gonna tell us what's gonna happen when we're in there arthroscopically. A lot of times that tissue is retracted posteriorly down the back. If you get in there and mobilize it from back to front, you're actually gonna get a decent cuff repair. So, again, options of treatment. Albert went over all the different things, but we look at cost, durability, complications, and outcomes. What can we do? So, and let's see. The other issue, thinking about these patients, you know, is just to be considerate of the number of revisions that we're doing. As rotator cuff surgery has increased, we know that there's a lot more revisions being done. Rotator cuff surgery's now the number one shoulder procedure done in the US. 10 to 30% of those revisions, that number is going up. So it's nice to have these other options. So for this patient, you know, we were able to actually mobilize her tissue pretty well. And you can see, advance her infraspinatus up. And this was kind of a trick question, because we were able to just fix her cuff tear, right? I didn't have to do anything with this patient, nothing, and didn't have to move the bicep or use it in a specific way. As far as using anterior cable reconstruction, you know, this concept has come around again. And I think with the fallout of SCR, so SCR, I was doing SCRs, a lot of them, a few years ago, and now that's kind of fallen out of favor, because we're seeing a higher failure rate. So people are looking for something else to do. So this anterior cable reconstruction has come about, particularly for large rotator cuff tears. So this kind of shows some stepwise techniques. There's different techniques that are described in the literature. Some people leave the bicep anchor intact and just shift it posteriorly to use it. Other people are detaching the bicep anchor and rerouting it. I think all those options are fine. There isn't great data to suggest one is better than the other. I think, the one I think is the easiest and the most is leaving it attached. Similar to an SCR, where we were tacking that dermal allograft medial on the glenoid, just leave the bicep attached, and then you can release it from the groove and shift it posteriorly. So for me, that's been the easiest way. And that shows, the picture on the right is a cadaver model. That shows it on the left, or I'm sorry, kind of what it looks like when you're done, and then the cadaver model's showing that you're attaching it to the infraspinatus. Here's another case. It's a 58-year-old man, presented with a large, massive rotator cuff tear. No significant fat atrophy, look pretty good. So again, options, you can arthroscopic debridement, partial cuff tear, superior capsule reconstruction. You can do interpositional grafts. The tendon transfers, like Eric just talked about. Balloon interposition. I do do some balloons in my practice. I've had a little bit of experience with that. And again, it's about maybe 70% get a decent outcome, but I'm very careful in my patient selection with that patient. And then you could also offer a reverse, which again, I think is the last option. So this shows how I do it. I like to leave that bicep attached to the tubercle on the glenoid. I repair the infraspinatus, get the best partial repair that I can, and then just do a side-to-side repair, release the bicep tendon from the groove, I'm sorry, release any attachment there, and then do a side-to-side repair, shifting that bicep posteriorly to be more right on the top, all right? So, and that kind of shows the movement there of the bicep. And it's, you know, if you've done an SCR, this is a much simpler procedure. You just shift it posteriorly and let it right on top. So how do they do biomechanically? Well, there aren't a ton of studies out there yet, and cadavers, they measured range of motion, superior migration of the humeral head, and subacromial contact pressure. ACR for stage two and three tears showed significantly higher range of motion at all angles. They demonstrate significantly decreased superior translation, which is nice. So you do get some depression of the humeral head when you shift it back. This study looked at, compared different fixation techniques along the head of the bicep for SCR. And again, all these different techniques, irrespective of the fixation type, the long head of the bicep augmentation significantly reduced superior migration, increased abduction angle, and decreased subacromial pressure, which is great. That's what we're trying to do. This is a little bit different technique, but Pat Denard has done some work on looking at using a semitendinosus. So taking a, you know, semi-T allograft and rerouting it, very similar to an SCR. And again, that cable partially restored the superior stability, reduced peak subacromial contact pressure without affecting glenohumeral kinematics, which is great. So again, this isn't really a new procedure. It was first described in 1975. There was a description at JBJS of rerouting a hypertrophic flattened long head of the bicep to depress the humeral head in cases of irreparable rotator cuff tears. So, you know, what goes around comes around. In the 90s, it was also described, there was a series published that showed that 85% of patients reported being satisfied with their result, okay? So more current studies done with my good friend Dr. Voloshin in New York, again, showed somewhat a unique technique where he used the long head of the bicep to reconstruct, augment the anterior cable. And again, he didn't really connect the rotator cuff tear to it. He just shifted the bicep over by itself and used that as a superior depressor. So again, another study out of Korea, improved clinical and radiographic outcomes seen after SCR using long head of the bicep to an autograft. So, you know, the way it take home point's really, this is a readily available graft. It's cheap, right? You don't have to, if you're working at a surgery center, it's readily available. Autologous, you're not taking a part of somewhere else. You don't have to worry about any disease transmission or rejection. It's biomechanically sound. The technique is not challenging. It's much easier. If you did an SCR, this is a walk in the park and much less suture management. And, you know, just something to have in your toolbox, I think, when you are addressing these challenging tears. So thank you. I'm excited to see that it wasn't a fringe thing I was describing today. A lot of people are talking about it. Who here in the room's done one? All right, so yeah, look at all the people doing it. It's great. Yeah, it is amazing. It is a old but new technique. My name's Ivan Wong. We'll talk about allograft bridging reconstruction. So thanks for having me here. So hopefully by the end of this session, you'll be more familiar with why bridging reconstruction may be better than partial repair, why recreating anatomy increases the healing potential, how bridging can protect the remaining supra and infra muscle bellies, and how bridging reconstruction can work for you. So how do we typically repair rotator cuffs or what do we do for our treatment algorithm? Well, we're not talking about the cute ones where you can actually get it back down. We're not talking about the arthroplasty ones, the older chronic that you wanna do arthroplasty. You're really talking about the ones that are in between. So the different options that we're actually talking about today, just like Albert talked, partial repair really is what we're supposed to be comparing against, right? That's the gold standard. And we wanna make sure what we're gonna do has a potential to be better. This maximal repair with Steve Burkhart talking about the suspension bridge reconstruction, you hear about this anterior cable, right? We want some kind of connection between the cuff, both in the front and the back, to allow the remnant cuff to work. So we have data. We do know that repair works. It can get good results, or partial repair can get good results in low-demand patients. But we're finding that it can increase the arthritis afterwards to progression to rotator cuff arthropathy that really reverses the only thing left. So this group in between, what are we talking about? And Eric talked about this very clearly. The muscle is the most important part. And what we really need to decide is how much muscle can we get back to work? Because if you're gonna transfer a muscle, that muscle transfer is gonna go down in the grade. We already have data also showing that lower trap is less than half as strong as the infraspinatus at its best time. And as we get older, that muscle gets worse. So what is it that we're gonna do and when are we gonna do something else? So the bridging reconstruction is really started with my fellowship director, Steve Snyder. He started this. I went there, learned it from him, and honestly, I saw how good the results were and I just couldn't believe that the rest of the world didn't know what this was, really because the research wasn't there. So if you wanna do this technique, what is the ideal patient? You know, this massive cuff tear, we were talking about this all together, but it's not what you're looking for there, it's what you're looking for here, right? You gotta have half of your muscle remaining. If you have half of your muscle remaining, we can get that half remaining muscle to work normally. In fact, we know if it's got half the muscle, it'll work as good, if not better, than the lower trap. How's it look like? Well, this is a view from posterior. We're looking at it here. You can see the retraction of this muscle. Oh, this patient already had two surgeries before, a mini-open, an arthroscopic repair. They said it was too stiff, couldn't get it to the footprint, and sure enough, we can't get it to the footprint. So they just did a debridement, a maximal repair. It didn't hold. He wasn't happy with it. He was a bodybuilder. So we try to do the bridging that Steve Snyder has taught. So here you can see what he calls the goalpost anchors. We move the infraspinatus, teres minor, any piece of tissue up. This is in the front. We're getting the biceps in situ tenodesis. Some people call that that anterior cable reconstruction. And then we go around the horn. We get stitches everywhere because the failure of cuff repair is suture-tendon interface. So we do a lot of suture management. It is technically demanding, but if you follow sequential motion that Steve teaches you, you won't get these tangled. We now have multiple collar sutures so we know where everything goes. And with the dermal graft, we know that the dermal graft allows for growth in there, and we know that it's stronger than most other things out for graft tissue. So we can get healing going on inside and cover up the hole, reconnecting infra and supra back to the tuberosity. This guy, one-year outcome, again, not normal. If you look at it, it's tough to tell the difference between the two sides. Again, he's had two previously failed surgeries. External rotation, we don't get it fully that way. But when you compare it to his other side, it's actually pretty close to the other side. And you gotta remember, he didn't have this motion for several years before we tried to do this operation. And we can get it back to the right spot. His two years MRI, you can see the tendon is not normal, but it's reconnected. We actually, the muscle in between is almost still there. And this is what we want to go through to make sure, are we getting this muscle working that way we want? So I do think if you can get a grade two or less than 50% muscle atrophy, we can get that muscle going, and we can get hopefully much longer lasting outcomes. So how does bridging reconstruction repair? Well, it took a lot of years after fellowship to get this randomized trial going, but we did a level one trial comparing maximal repair to bridging reconstruction, 30 patients, 60 years of age, mostly male, with almost five years of outcome, sorry, four years of outcome. And what we did find is the healing of the bridging was significantly better than the partial repair. What's more important is partial repair, we always say doesn't burn bridges, but 20 percent of these patients progressed onto severe glenohumeral arthritis, right? We got to go to a reverse. There's no other surgery. We can't do another bridge, or ACR, or SCR, or anything else afterwards. So you just got to understand, maximal repair in somebody who has no arthritis before, who had muscle, we can make it so that they'll never get that muscle back again. You can't do a lower trial. So why does it work? Well, if you do that suspension bridge technique with that anterior and posterior anchors, you get a lot more forces in that area, just like a suspension bridge. If you put a graft in between, you distribute all those forces through the whole area, and we're using 11 other sutures to do that, so it makes it much easier to distribute that across. This is our current year's fellow, Jill. She's actually presented it on Thursday here at Anna to show the radiographic outcomes. And what we do find is when we look at the post-operative versus pre-operative MRI, looking at the muscle mass, both supra and infra in these massive tears get maintained. You can see this is pre on left, post on our right. The tendon is not normal, but it has now reconnected supra and infra. And the muscle, though not normal, you can see it can be scary, but two years afterwards, we maintain that. We can see the function. They actually go back to sport. They play tennis and, of course, Canada hockey. So here's a six-month outcome from, you can see on the left-hand side there, that's his right shoulder we did six months ago. He's able to retrain his infraspination to work properly again. This patient on the right there is a left shoulder three and a half years after surgery. And you can see they do maintain this extra rotation strength that they didn't have from before surgery. So what's their survivorship? We actually published our midterm results, so this is minimum five-year follow-up in the Green Journal. We find that all their outcome scores are maintained this way. It's not like an SCR that seems to drop off over time. Not everything heals, right? We're getting about 73% full healing, where we can see the connection between the graft and the tuberosity, and that's what we really want to do, because I think that's what our goal is. So if our goal is that, we want to see how well it maintains that way. And then in our follow-up, so now we're looking at more than five years, so it's a mean follow-up of 7.3 years. We've had one patient that went on to a reverse total shoulder, and then two that progressed with arthropathy. Again, another one, these are older individuals, which really can do functional motions, getting them back to what they want to do. Why I want to show this, because everyone says, well, really, what happens? Does it really heal? Well, this is one example. We did a bridging reconstruction. Three years later, he's gone back to play hockey, really enjoys it. He dislocates his shoulder, running into the boards, and this is his MRI. You can see on the top there, these are all the same images during that same time. The top there, you can see where the cuff is reattached, right, with our bridging reconstruction. But in the posterior aspect of it, you can see a hole through the graft. Even though it's tensioned, it's just not tensioned quite enough. This is what it looks like, so three years afterwards. We had tied it to the biceps. That's the anterior edge of the graft, sewn into the biceps. You can see the vascular channels in there. Again, three years after surgery. Looking around here, he had no cuff, no supra, no infra. It's healed medially. You can look here. As we look backwards, we're going to pull back, we're going to look up, so you can see, it looks like a rotator cable, right? This is dermal graft. It's not his native cuff anymore, but it has the same shape, kind of reattaching. You can see our sutures where we reattached it to the greater tuberosity, but we changed the camera angle to look down. He actually tore, because he dislocated his shoulder. Maybe that's a Hill Sachs, maybe not, but you look down, this is where he ruptured. You can see it tore through the suture area, where the graft had attached to infra and teres area. So if we look, this is from the inside, if we look from the subacromial position, you can also see the exact same thing, and I think it's still this one that goes through. So we look from the subacromial area, you can see the posterior aspect. So this is the posterior aspect, infra, teres area, you can see the vascular channels going into the graft. Again, graft is not normal. It doesn't heal back to a normal tissue, but it reconnects what we want. So we're able to get this back together, and then with this, we can do another repair. So we actually just do a revision repair, and wouldn't it be great if you come in for revision surgery, and you have more tissue than you had in your initial surgery. So how can you learn this? Well, we now have different ways to be able to do this. COVID's been really good at teaching us how to be resourceful and how to use our current technology to do. This is one where we collaborated with India. We did their course. We can use multiple cameras, show exactly what a patient does before surgery, teach them all the steps, because this is a technically demanding surgery, but to transmit all that information across using holograms, using augmented reality, we can really identify where the portals are, why we do them in a certain way, how you keep them organized, how you can stack these grafts to make sure the suture is in the right spot, the planning for this, the roadmap. We actually have a guidance so that the entire team knows exactly what to do, and then we try to do all the complicated parts of the surgery outside of the body so you minimize your chance of tangling them inside and really just becoming an art of passing sutures and tying sutures. Hopefully, we've shown you that our algorithm, if you have muscle, we can actually reconnect it and make it work again. And our treatment algorithm, because if you don't have muscle, I agree, you can't make that work. Thank you. All right, everybody. Good morning. We are going to talk a little bit about the balloon. Okay, Albert assigned me to tell you how I get the same results with a five-minute procedure. Disclosures are important here. I get research support from Stryker for a level one study that we're doing on rehab after the balloon. No royalties on the balloon for me, and I think if you asked Stryker, they would say if they were picking someone to do this talk, they would probably pick somebody else. I'm kind of like balloon curious, surgeon, I'll try to maintain a little bit of skepticism about it, and hopefully you'll appreciate that these are my own thoughts about the balloon and not coming from Stryker. So I come from San Antonio, that's Rockwood country, instrument of the devil. I've been told that what Dr. Rockwood really meant by this is that the arthroscope was a tempter. You would see things with the arthroscope that would tempt you to do things that you wouldn't normally do in open surgery. Also Burkhart country, another instrument of the devil, the reverse shoulder replacement. So the easy button, that was Dr. Burkhart's kind of view, you know, surgeons, we attempted to do something easy when the hard thing was the right thing to do. So I'm here to tell you about the ultimate instrument of the devil, which is the balloon, which is both an easy button and actually has a lot of perverse incentives for the surgeon. So caution. A lot of the talks that you've already seen have been really technique focused. The technique for the balloon is ultra easy, and so there's hardly anything to say about it. There's a few Medi videos if you want to get some of the pearls, but there aren't really that many. Basically, size it correctly, and if you're in between, go to a larger size. And don't destroy the walls of kind of the subacromial bursal space that that patient's generated with their chronic rotator cuff tear. So preserve the CA arch, preserve the margins of the bursa. Don't debris everything away, because otherwise you'll predispose the patient to balloon migration. Reimbursement is a serious instrument of the devil issue. The institutions stand to benefit substantially from the facility fee from the balloon. So both hospitals and ASCs profit a lot from balloon cases. Not when it's used as an augmentation, which is off-label, but if it's used as a primary procedure. I'm going to tell you my conclusions first. Should be narrowly indicated as a subacromial surgery option for massive irreparable rotator cuff tears. They should be elderly patients, low demand, preserve motion, preserve subscap, minimal LOA, and patients that you think could benefit clinically from a short surgery time. Level one evidence that the balloon is non-inferior to partial rotator cuff repair only in older patients. Level one evidence for poor results from the balloon in the UK, Albert already mentioned that study, versus debridement and tenotomy. Bunch of level four evidence that you can improve patient outcomes in properly selected patients. Because many massive rotator cuff tears have a favorable natural history, so you're really harnessing that phenomenon. For me, this is really an indication of exclusion. So you have an elderly patient, their motion and function is too good for reverse, their tear is too bad for repair, they won't heal it, they're not going to be compliant, they've failed non-surgical treatment, you know, with injections, therapy, maybe they don't believe in therapy, that's actually, I think, kind of a good indication for it. And poorly tolerant of a longer surgery time. And you might just say, well, why don't you just debride those people, and that's a good question. Okay, so this is supposed to be a case-based discussion, so here's a case. This guy had a fall, let's just say, ten years prior to presentation. It healed, you know, which means he did okay after it. He's kind of a country bumpkin kind of patient, not like a Northern California patient, you know, likes to fish, not on a yacht, a smoker, he's not quitting smoking, you know, he's like one of those people who's going, these cigarettes are the only thing keeping me alive. He loves smoking, he loves smoking. Full motion, bad cuff, so ten years ago he had something that you would probably go after, and now he has, you know, a poor chance of healing some sort of soft tissue surgery. All right, so that was like a really long introduction, a five-minute introduction and a ten-minute talk. Okay, so here's another algorithm, don't look at it, it's just the point is, these patients are challenging because there's so many different, you know, options, and they come in so many different flavors and, you know, ways that they present, and there's different goals and everything like that. So, you know, pain relief is a reliable for most of these operations, which is what we're after, so, you know, it's hard to make the right decision for them. I think these people are fun to take care of because you've got to be kind of, you know, a real doctor for them and, you know, do some complex decision making. So what I would like to propose is that there are these, there's this group of patients that you should have a minimal kind of subacromial option for, and whether that's just a debridement or the balloon or maybe some of these, like, subacromial resurfacing procedures that are kind of quick, identifying those patients and having an option for them is a good part of, if you have a massive cuff practice. Really important to know, so many of these patients have a favorable natural history for their chronic rotator cuff tear. So PT can be very effective, this is Moon Group data. People who believe in physical therapy have the best, you know, chance of doing well in that scenario, so their belief, their way of thinking about their shoulder matters a lot. I got interested in, you know, for me this used to always be complicated surgery, but once these kind of longer term SCR results started to roll through that I was observing from Dr. Burkhardt's practice, I took over his practice after he retired, I got interested in this. So this is an SCR patient, revision cuff situation, so that's starting, here's their SCR at one year, here's their SCR at five years after surgery, SANE score, 100%. So it's like, maybe we can get this with something easier, you know, than a $15,000 operation that takes four hours and, you know, a part of your soul away. So, you know, excuse, like forgive me for digressing a little bit and trying to like get into a little bit of why, you know, what is the balloon really doing for people? So Ivan just said this, you know, the bridging reconstruction, what's the specific effect of that operation? You know, what are you trying to do? You're trying to sew some stuff together and to get it to heal. So, you know, all of our operations have that, especially these soft tissue surgeries, you know, gristle surgery, and then there's the nonspecific effects, like you're getting some, you know, indirect benefit from the patient going to therapy, a debridement, treating the biceps, whatever. So the balloon, short term, clearly has some specific effects. It makes a, you know, a smooth surface in the subacromial space, it cushions, it improves the biomechanics somewhat, at least, you know, as Albert said, in vitro. Nonspecific effects, the patient's engaged in PT, you know, they're doing, maybe they didn't do that before. Long term, that we know of, none. This is a bioabsorbable device, it goes away. So it's like, what the hell's going on there? Why don't, why are they getting, why are they better when the balloon goes away? It's because you've reverted them to a favorable natural history. If they are going to have a favorable natural history, that's my view about it. Or maybe you've just given that patient a long term reason to do physical therapy. I don't know. You know, we don't really know. This is just me sort of speculating about the balloon. These are my cases. So prior to becoming a site in this Stryker study, you know, I just was prospectively collecting through SOS data on my patients. So this is 15, this is my first 15 patients, four clear failures. I think that's what pretty much everybody has found who does balloons, about 75, 80 percent kind of chance that they're going to do well. And the patients who don't do well declare pretty darn early that they're not. So that's what I tell people. But pretty good for like a five minute surgery on their SANE scores. So if you choose these people right, they'll do well. Again, don't look at this data. Just, you know, systematic reviews show retrospectively patients improve with balloon. They get better. Low risk of complications. That's important to know. So, you know, we're trying to meet, I think, a low bar for some of these people. Balloon safety is a big one. So if there's no, I hate, we're not burning bridges, you know, every operation has effects for the next one. But the risk of complications for this is pretty low. Balloon migration is probably the biggest one. Okay, so a couple of things from the IDE study that's published in JBJS, 80 percent of partial cuff in the balloon met MCID. That's a real low bar, you know. That's a really, really low bar. So not surprising. Only 50 percent are at an acceptable symptomatic state. So it's important to know that. Range of motion and OR time favored the balloon. No device related complications. Reoperation rate 4 percent. This is really important to know. These patients don't get better really fast on average. Takes about three months for them to get their range of motion back. So it's important when you counsel them. A lot of them that end up doing well behave like a difficult cuff rehab. You know, the people that probably are failing their rotator cuff repair, you're nursing them back to health, you know, over a year or whatever, and then they do okay. This is very important to know. Patients less than 65, they didn't meet the non-inferiority criteria for the FDA. So that's why the FDA did not approve this for patients less than 65. Partial repair did actually better than the balloon. So this is an old people surgery. You can find bad results from the balloon. You know, the start reacts. The UK trial is one. This is a retrospective study that's like that. Inconsistent results. And then if you look in the details, it's not hard to understand why. On average, these patients were, you know, had poor motion. Four were pseudo-paralytic. They revised them pretty early, six, six, seven months, you know, so they weren't patient enough. You know, if you pick poor patients for this surgery, you're going to get poor results. So that's probably like the UK study, we think. A lot of subscap tears. They were pretty big tears, actually. Very few of those were repaired. So probably didn't pick the best patients for that study. Okay, so I'm out of time here. So this guy did great. You know, not everybody's like this, but our smoker fisherman guy, he's cured after like, you know, one week and then, you know, never looked back. When the balloon deflates, if you're doing this, you need to know this. So when it deflates around three or four months, they'll have kind of a little dip in their outcome. So you have to just encourage them and get them through that. This guy didn't have that, but that is a phenomenon with the balloon. So Dr. Burkhart taught me this. There's the easy way and the cowboy way. He meant by that, do the right thing, especially when it's hard, but it doesn't mean that everything has to be hard. So instrument of the devil or a devilishly clever operation, you know, you decide. Thanks guys. All right, really, really great talks here. I'm going to pull up the first slide up again, since we have some cases there and we have I have about 20, a little less than 20 minutes here, and hopefully we can get through two cases. So I'm gonna spin through all of this here. You'll have to bear with me as I do this. All right, so here's a case. This is, I think this is up, this is like the San Francisco patient here. 72-year-old, he's left hemdomyne, he's very active. He's got great range of motion, and this is, these are the only images that you get here. So, you know, Sarah, what do you think of this? Yeah, so again, these 72-year-old active people, these are my people, which is great. You know, he is, when I look at this patient, you know, again, I see no arthritis in this patient. There's no significant narrowing of the chromohumeral interval. So I look at those x-rays, and that makes me happy. Obviously, massive cuff tear. Looks like there's some fat atrophy, both the supra and infra, extending back. You know, it's interesting. And we've talked about this in sort of the theme. And a lot of people would look at this and maybe just push the easy button and say, we're going to do a reverse replacement. But I would argue this patient has a really, really good range of motion. And if you do that, you might actually compromise their motion. And so, Ivan, if you would. Albert, I was just going to say, yeah, reverse, this is the case we debated yesterday, wasn't it? Sort of, yes. OK. So I wanted to make the point about this. I didn't have time. But if you do a reverse in this patient, they're going to be left with very little rotator cuff. Because you're going to cut their subscap, unless you're doing cuff-spearing reverse. You're cutting their subscap. If you repair it, it's probably not going to heal. So then they've got their teres minor. And I found these patients to be like, because sometimes you just have whatever they wanted, or who knows. But they are dissatisfied with their strength. Yeah, and I think it was, if you were there at that session yesterday, about 50% of the audience pulled the reverse, actually. And so. I was shocked by that, actually. Right, and so I was actually shocked, too. Because somebody has well-preserved motion, and they just have a pain issue. And so, I mean, you're shaking your head here. So is this the kind of guy is, if you look at the muscle quality here, is this somebody you think that can improve with bridge allograft? Or does this person need something else? Yeah, so these are the important things that I would like to go through. So no arthritis. But this is a single cut. So this is why it's really important. When I asked for an MRI, I wanted to go all the way to the medial aspect of the scapula. My fellows here, you can ask her how often I actually get that image. It's very rare. But if they can get it, you can see where the muscle is. Because a massive tear, the muscle tends to ball up. And the majority of the muscle, if there's remaining, tends to be more medial. In this case, I'm looking at it. You can kind of see the why. I think you're just medial to the glenoid. So I'm guessing there's going to be more muscle medial. If there's more muscle medial, and the motion's great, they have a fantastic chance at a bridging. And we have great outcomes now. It took us a long time to get the MRIs to show that, look, it can maintain for years and years if you can reconnect it. It's interesting. I think bridging allograft kind of went out of favor for some period of time. But I think it's because people weren't doing it the way that Ivan does it. And what I mean by that is you see sort of the goalpost, suture anchors, fixing the cable. The cable is nicely restored. You don't just simply just bridge it and have nothing attached on both sides. And I think that's why your outcomes are so different than some of the other ones reported in the literature. Sarah? I think the other thought with this is, I would go into this case expecting to get a full rotator cuff repair and hope that you could completely repair it. And when I see atrophy like that, this is someone I would consider for a patch augmentation at my index procedure. But I would try to get it primarily fixed as my first plan. Great point. And then, Eric, if you look at this, is this somebody whose motion is just simply too good for a tendon transfer? Yes. I mean, so clearly this patient has done a nice job of just inherently rebalancing their shoulder. They have a big teres minor. They have a subscap that's maintaining the anterior. So they're better than others who had the same tear pattern. So likely, with the exception of the reverse, likely whatever you do, you potentially are going to help rebalance their shoulder. In my mind, there's like two considerations here. One, I agree with Rob's comments on the reverse. Larry Glaude and others have studies that people have preserved motion that you go to a reverse in, especially in the setting of massive cuff tear. Those patients are the ones that are dissatisfied after the reverse. Those are the ones who don't do as well and are not going to be super happy with you, despite even if you do a perfect reverse and, let's say, you don't have impingement for your motion, all that stuff, they might still have some sort of weakness because of their cuff atrophy. And they might lose some actual motion. So be careful about those. Second, for this case, I 100% agree. And as I mentioned, so repair what you can. And in my mind, I bet you'll be able to get at least a lot of the emphastomase over. Maybe you'll have to bridge it. But I bet you'll get a lot of the emphastomase over. And then the question you have is, is that enough? In my mind, no. And that's why I said, infrastate is perfect. You get as much as you can. But you have fat infiltration. That's not normal muscle. That's when you add in a lower trapezius transfer in this case. Because I think, as Ivan said, it's not going to replace the whole posterior superior cuff tear. If you have no tears, no infra, no supra, you do a lower trapezius, that patient's not going to crush it. They might get some active external rotation back, but not beyond neutral. And it's not going to crush it. If you have a functional posterior superior cuff, like he does, and then you add in lower trapezius, I really think you can get this patient back to normal motion. And our data sort of suggests that. So in my mind, yes, I would probably do a lower trapezius. But I would, first off, repair what I could with this patient. I mean, I think this is a perfect example of how complex the decision here is, how many treatments you could possibly consider here. So I'm going to poll everybody in the faculty who will also raise their hands with all these polls, too. So who would do a debridement, margin convergence, partial repair? Or a full repair? Well, full repair, everybody, I think. All right. So who would do that and combine that with a biceps ACR? So here's my question. If you have pre-existing bicep pain, is that a patient you want to do the bicep ACR? That's interesting. I don't know. We see a lot of videos of the biceps, and they're kind of shredded. And I'm with you, Sarah. I'm a huge biceps killer. But in these patients, in my own personal experience, I probably have about 10 of these now. I leave the biceps actually attached distally and move it. And I haven't really experienced patients having a huge biceps problem, which is a little strange to me. So even with 50% biceps tear or fray, again, I just do what Snyder taught me, which is just in situ tenodesis into the top of the groove. And then I use that as whatever you call anterior cable repair. I put my bridge into it. I attach whatever cup I have remnant into it and it seems to improve. Yeah. It's a very interesting thing. So how many people, when you do a biceps cable reconstruction or in situ repair or whatever, how many people leave it intact distally? And then how many people cut it and do a tenodesis distally? Yeah. Really interesting. All right, so we have those two. We have tendon transfer. Who would do a tendon transfer for this patient here? Bridge allograft? OK. SCR? And then balloon or tuberoplasty. All right. So I'll show you what we did. This was many years ago, actually, before sort of I probably would have done two, which was partially repaired to an ACR. But honestly, we did margin convergence on this patient. We simply kind of put the two together. And I think there's some anchors maybe posteriorly. Patient did great. So I mean, I think it just belies sort of what Rob was saying about sort of the, you know, the non-specific effect. The non-specific effect. Yes. I bet this patient would have. This is the classic one where you can do anything. Yes. They would have been fine with a debridement or a healed or non-healed bridging reconstruction or the balloon or whatever. That's why I presented this. Because I think in a patient who has preserved motion and their only complaint is pain, I mean, we could talk about all of these. So the reality is I think you debride it and you could do something. You could put a balloon. You could probably do many things here. And I think they're probably going to have a pretty good outcome. Sorry, Eric. Do you want to? No, go ahead. One thing that I failed to mention about that, or maybe I did say it. For me, the balloon, if it doesn't appeal to the patient, I just let it be. I'm not trying to sell balloons to them. Some people, like, they look at it and they're like, they love the idea. You know, it looks so soft and cushiony, you know? And then when I tell them it's going to, like, resorb, they, like, ignore that. You know, some people get fixed. It's going to absorb? Like, well, then what the hell is the point of the surgery? We're doing another one. Those people also, it's like, OK, leave that. You know, the people who love the look and then ignore that it's resorbable, like, they're the best for it. One comment, if you do a reverse in that patient, that weakness that you said, the 4 out of 5 weakness, that potentially is not going to actually improve. And as a note, the motion might actually drop. So I would actually argue, in my mind, that's, like, the one option I don't think is so reasonable for these preserved motion is because you might even have an inferior outcome to that. Even though maybe it'll stand the test time longer, I would disagree. So I think you're right, except for I don't think a reverse, even though you showed this yesterday and everybody voted to reverse, I don't think that's one I would even offer the patient. Yeah. And I just want to make one more comment. Even though this patient, we say, look, you could do anything and they could be happy, the reverse is also true. We could do something and they could make it really bad, right? So they have preserved motion, preserved function, just as pain. And if we screw up their balance, they're going to be miserable. And it depends on how we screw it up. If we do a reverse, there's no coming back from that. If we do a partial repair, it could fail. And as long as we get back to it soon enough, we have lots of options, right? The muscle's not gone. The only reason why I say I choose a bridging is because, at least now, I know that the muscle's not going to go away. And if I go back, I'm actually going to have more tissue and more options to choose. So just be careful. What you choose really matters, especially for those ones. Because if we make them worse, you don't want to be the one to screw up all the other options. Hey, Ivan, I'm going to propose something to you that I've talked to Eric about. Do you think that the lower trapezius sometimes, that transfer, there's some good muscle still, that graft is going across the infraspinatus, do you think it acts as sort of like a bit of a reconstruction of the infraspinatus sometimes? So yes is the answer. I love the idea of the lower trap. I really think the lower trap in a bridge is almost the same thing, is you're actually taking even more muscle to go across it. Sometimes I just worry that is, so we tend to jump the gun. When we started doing SCR, the trouble I got worried is, I look at these MRIs and these persons, they have a small cuff tear. And we jumped straight to SCR. That's, you're wasting all this muscle. Now we go back for revision, they got no supra, no infra, no anything you're to reverse. Lower trap, I love. The concept is fantastic. But we have other options, maybe, right? So if there's muscle, I'd rather put their own muscle back down, because when they get back, as we get older, I think the patients I use is a little bit different, is they failed everything else, multiple revisions, the supra and infra is completely gone, but even their lower trap is weak. So I don't get the same amount afterwards. So again, does it work? I think it does augment, and I think that's why in the right patient it can, but you don't want, so what you do is fantastic, where you actually repair infra, just be aware of what you're doing. Yeah, I mean, I think the take-home point for this, I mean, we're all experienced shoulder surgeons, and in this patient, all of us, I think, are really, really hesitant, or not even hesitant, but we don't even, like for me, I don't even consider a reverse in this patient. Patient is too good for a reverse. So just food for thought, if you see a similar scenario. We have five minutes here, I'm gonna, this is a little bit of a different scenario. 49-year-old, he's a carpenter, acute and chronic, now he comes to your office a month later, he can't lift his arm, he's got very poor elevation, so kind of like acute pseudo-paralysis, but not really true anterosuperexcape. He has no lag signs. This is how he presents to you. And these are his x-rays. I will kind of show you some spot images here of his MRI as well, so no arthritis, no really cuff arthropathy changes. So what do we do here? Sarah, what do you think here? I mean, this is a young guy, so I would go in, attempting to repair his cuff, and then have the other options as a backup. And honestly, 49-year-old labor, most likely gonna do, oh, he does have pseudo-paralysis? I thought you had full range of motion. I'm like, we just saw full range of motion. I guess the definition of like 30 degrees of elevation, but he has no anterosuperexcape, so it's not like his humerus is escaping out of his shoulder. Got it. Okay, so someone like that, I'd be more likely to think about a tendon transfer operation to try to help him get more strength. So the question is, is it limited by pain? Sometimes they're limited by pain. It's hard to know sometimes, right? Rob, sometimes we talk about this pseudo-paresis, pseudo-paralysis, you know, what is this? So 30 degrees of active elevation, but the head's not riding high. Is this true pseudo-paralysis, or sort of, how does that even enter your thought process? It doesn't enter it that much. I mean, you know, he's got a bad motor problem, so the stakes are high, and he's young. Like, that's how I think about it. So does that? Because I'm not, like, I mean, I'm not committed to, I think within people that have a bad motor problem, like, there's acute and chronic. That's, to me, a bigger question, you know? Because if somebody comes in, it's like, hey, how long have you not been able to raise your arm? Oh, a year. Why didn't you come in? Oh, you know, there was some bad stuff going on in my life, whatever. Like, that's a bigger differentiator to me than how much, what's the degree of elevation that they have, you know? If some guy comes in and says, you know, I fell, and now I can't raise my arm, and it's been two weeks, or three weeks, or two months, I'm like, I don't care how much, I'm going after that patient, you know? Whether they can do this, or this. Yeah, you know, I think that's an important distinction, because when we say these buzzwords, sometimes you just assume that this person has had a chronic problem, and they can't lift their arm, but this guy, obviously, was functioning pretty normal. He probably had some chronic changes, but now he has an acute and chronic problem. Maybe. Maybe. There's pseudo fatty infiltration, you know? There's those patients that, it looks kind of bad, but like, it's just because they have an acute cuff tear. You know, there's some MRI changes that I think can be misleading. You gotta look at the T2s on that situation. Make sure that it's not bright. Right, Eric? Great point, yeah. So there was maybe a little bit of brightness, but the whole thing did not light up like an acute problem. So, what Robert was saying, when you have an acute retractive tear, you get, I think the T2 signal changes you can see on these acute retractive tears is you get traction of the nerve, and I do think you get, just like if you have a nerve injury and you get a T2 MRI, let's say somebody has traction injury during surgery, you get a T2 MRI, their cuff lights up. I think it's the same thing here. You get acute retractive tear, I think it retracts, I think you get some traction on the spinal glenotch, the supraspinotch, I do think you'll see that, and that's the point he's making, is that sometimes you can get tricked with. You have to be very careful. So yeah, sometimes you can get tricked with the presence of an acute tear coming back, and then you see this kind of fat infiltration or signal versus a true chronic fatty infiltration, and I think that's a big difference, and a big differing factor in what you would do for these patients, especially patients like this that are highly active and now have pseudoparalysis. The other point is there are studies that have shown acute pseudoparalysis, patients will present with acute pseudoparalysis and you rehab them, and they actually correct it themselves. There's a multi-center study at the French Arthrostic Association showing that. So remember, these acute and chronic situations, pseudoparalysis does not the same in acute and chronic setting, and at least in my mind, that's a really important, as Robin, as Albert mentioned, it's a really important differentiator because a chronic pseudoparalysis is tough, and then if you have escape on top of that, at least in my mind, that's a really tough problem. This is, it seems like an acute on chronic issue, but, and without tendency to, I can't totally comment, but at least it does look like there's some chronic parts of this. So the other thing I like that Eric brought up was when you have these either acute or acute on chronic issue, you need to look at the MRI all the way medial past the scapular Y because that will determine the real indication of muscle atrophy or fat infiltration. So maybe one, you know, Sarah's vote is for tendon transfer. We're gonna have like one option here that you guys pick. Ivan? Yeah, so I'd go for a bridge. Okay. Eric? Yeah, I mean, so, like I said, without seeing, as Milos said, like, in my mind, I repair what I can. There's probably an acute component of this, so you can get at least, I'm assuming I'm gonna be able to get some of it back, and then based off of what I can see here, I would add a tendon transfer, I guess. That'd be my backup plan for if it was irreparable. So partial repair with tendon transfer. Okay. If it was irreparable, I would do a tendon transfer. Okay. So we'll just pull everyone here quickly. So who is debriding partial repair? Okay. Partial repair with ACR? Who's doing an SCR in this? All right, tendon transfer? Partial repair with tendon transfer? What did I miss here? Balloon tuberoplasty? And then who's doing a reverse total shoulder replacement? All right. So this was many years ago. This is the biceps killing that I did here. At the time, SCR was very sort of in vogue for this, and I actually ended up doing an SCR in this patient. Now, to be fair, I don't have postoperative MRI, so I don't know if this is healed, but I do know that this is what he looked like one year post-op. And so he did very well with this. But again, just realize sort of how difficult these scenarios are and how many options, and I think the take-home point, you have to know sort of many things, what the demographics are, what you're trying to treat, function, pain, and consider all these when you're looking at your arm or midterm, what to do. So I really appreciate you guys being here. It's a pleasure, Saturday morning, to learn from the great faculty. I want to thank the faculty here. Thank you very much. Good job, Albert. Thank you, yeah, good job, Albert.

non-arthroplasty treatment options

massive rotator cuff tears

muscle preservation

anatomical restoration

debridement

partial cuff repair

tendon transfers

bridging reconstruction

patient selection

functional outcomes

bridging reconstruction benefits