All right, welcome everyone to this ICL. Thanks for spending your late afternoon to be in this ICL, and I hope it's going to be a stimulating conversation for you. The topic of the ICL is non-arthroposophy options for irreparable massive rotator cuff tears. And as you'll see from our awesome faculty panel here, which includes Sara Edwards from UCSF, Eric Wagner from Emory, and Ivan Wong from Halifax. We may not be very as close to this answer as we were even 10 to 15 years ago. And so it might just get even more muddy. And so the format for this will be, we'll try to give about 10-minute short talks. I'm Albert Lin from the University of Pittsburgh, and I'll be moderating here. So the format for this will be about 10-minute talks from our faculty, and then talking about some cases, which I hope to be able to stimulate some discussion with our faculty and from the audience members. And as we go along, please feel free to go up to the microphone and ask some questions. So Sara's going to be talking about a newer, well maybe not a newer, a newer, older procedure that has been popularized in Europe and Asia way before here in the U.S., but getting a lot of traction with the biceps. Eric's going to talk about tendon transfers. He's one of the foremost experts in tendon transfers in the world, and Ivan's going to talk to us about allograft bridge reconstruction, which, to be honest, I think if we pay attention to how he does that technique, you'll see why his results, I think, are a lot different than sort of previous reports in literature. And I'll be talking about the arthroscopic debridement and partial repair and why maybe we should be using that as a measure for, as our gold standard. So in terms of the order, Dr. Edwards is going to go first because she unfortunately has to catch a flight. And so we're going to have her give her talk, and then we'll proceed with the rest of the outline and format. All right, thanks, Sara. All right, thank you. Do we have a quick, oh yeah. We're good. Good afternoon, and thanks for being with us today. I'm Sara Edwards from UCSF. And yeah, I unfortunately have a flight at 6, so I'm going to be, you're going to see me speak and then leave. So I appreciate your attention. These are my disclosures. So guilty confession. I have traditionally always been a bicep killer, and I still am. I still like, I do a lot of bicep tenodesis, particularly when they have pain or any problem there. But this is something to be excited about. This newish technique has been around for a long time, but there's been a resurgence in it in the last several years. How many people in the room are doing superior capsule reconstruction with bicep? Okay, how many want to do it or are curious? Okay, right, a lot of people. So that's great. Hopefully, we will get you convinced that it's something to try. It's an option or a toolbox in your kit here of how to fix people. This is a case. This was a 55-year-old female equestrian. She fell off a horse over a year ago. She felt worsening shoulder pain and weakness. On exam, she had a passive range of motion to 155, 35 degrees of external rotation, internal rotation to L5. Active range of motion was only to 105 degrees with kind of that shrug test where she would using her accessory muscles to get her arm up there. Strength was weak. She was four out of five in her supraspinatus and infra testing external rotation. Her belly press was negative. This is what her films look like. So this is a significant defect of her superior cuff. You can see that. Subscap was still intact, which was nice. No significant arthritis in the shoulder. I will also say I come from a bias where even though I'm a shoulder arthroplasty trained surgeon, I really try to preserve a shoulder that does not have arthritis. I think we should try to fix those when we can, particularly in a younger patient. A lot of people are jumping to the reverse now. Earlier in a session, we were saying the reverse is now four to one from anatomic total shoulders. And a lot of that's from massive cuff tear. And again, I still think there's a role for trying to fix the cuff or do one of these alternative options, particularly in a younger, active person. You know, she has moderate fat atrophy. This isn't something I get too worried about. You can see it's like a grade two on her sagittal film. So your options in this patient, you know, you can do an arthroscopic debridement, simple debridement, partial cuff repair. Al's going to talk about that and what that's done for patients, superior capsular reconstruction. So the traditional ones, I used to do those as well. And, you know, about 50 percent, I think my results were very consistent with how the literature played out. So I think that's still an option. You can do the SCR now with the bicep. There's interpositional grafts, lat transfer, which Eric's going to talk about. You're talking about lat or trapezius? Lower trap. Okay. And then balloon interposition. We have any balloon people in the room? Potentially a few. That's kind of falling down a little bit. And then, again, a reverse total shoulder. So we have all these tools that we can use to fix people, which is great. Different considerations. What I'm thinking about, you know, what is the cost, the durability, what are the complications, what are the potential outcomes for these patients? And, again, this patient's showing the massive cuff tear. So in this patient, I chose to augment, do a partial cuff repair, and then augment the bicep and use that, incorporate that into my repair. And she did well. She was able to regain her range of motion. This concept has, again, drawn, kind of had a resurgence in the last several years, using the anterior cable reconstruction for proximal bicep tendon tears. There's a lot of different techniques that are described. I personally will drop an anchor both anterior and posterior to the bicep and anchor it to that, and then I try to do a side-to-side repair using the bicep. I keep it anchored to the glenoid, all right? So I don't release it from the glenoid. And in my hands, that seems to go well. Again, most of the time, I can advance that cuff tissue up. So I like trying to use the cuff that's there. This is some practice that we did on a cadaver model, you can see. And that's what it looks like on the right picture as well. You can see it tethered to the bicep. So this is another patient. Again, films look great, all right? There's no significant OA, but you can see a large, massive cuff tear. I always find it interesting, you know, anyone who has a large, massive cuff tear, they'll say you see this narrowing of the acromial humoral interval on the MRI because they're lying supine. But in reality, if you go back to the x-rays, you can see they don't really have superior escape at that point. So those are patients, I think, that are good to use this repair on. And this, again, shows the anchor anterior and posterior, the bicep, which is in great shape. So you can use it, even if the bicep isn't perfect and pristine, you can use kind of a ratty-looking bicep. And I'm advancing that and moving the cuff anterior and moving the bicep posterior to meet that tissue. So that's more just me debriding that tissue, another one. And again, translating that bicep posteriorly to cover where the supraspinatus would be. It's very simple. It's cheap. You can do this in your surgery center. It's just something you have to have a preoperative plan. So biomechanically, how do these patients do? There's several biomechanics studies that are out there. This one, in particular, looked at cadaver shoulders, measured range of motion that they were able to get, superior migration of the humeral head. They demonstrate significantly decreased superior translation for patients with stage 2 tears and external rotation and abduction. Another cadaver study underwent three types of different long heads of the bicep tendon fixation for an irreparable posterior rotator cuff tear. All of these, all the techniques, whichever one you chose, had reduced superior migration of the humeral head, increased maximal abduction angle, and decreased subacromial pressure between the humeral head and the acromion as it went into abduction. This was another biomechanics study done by Pat Denard. Again, his technique was a little bit different. They used a semi-T allograft to make it V-shaped. Now he's using bicep, but also restored that superior stability, reduced the subacromial contact pressures, which is our goal, trying to keep the shoulder from raising up, keeping that pressure off the subscap as well. So again, ACR with long head of the bicep tendon is not new. So it was initially described. This was the first series done in the 90s, really. They looked at 14 patients. 85% of patients reported being satisfied. And then more current literature, this is a study done out of Rochester Ilya Voloshin, who's a good friend of mine. Again, he used a technique where he advanced the bicep back. He kept it in continuity on the humeral side and used it as a bridge. And again, excellent outcomes in his patients. This is a study out of Korea. Healed patients, significant improvement in all parameters except internal rotation. 77% of patients displayed a 17-point improvement. Acromial humeral interval increased by 2.7 millimeters. And that was in live humans, not in cadavers. This is really the best paper out of the US, published two years ago in Arthroscopy by Larry Field, who's very active in this organization. 30 massive rotator cuff tears augmented with a bicep SCR. All patients had significant improvement in pain and range of motion. So good results so far. So take-home points, this is a readily available graph. Obviously, a lot of us have financial constraints that the institutions we're working at. So this is a nice option for that. It's biomechanically sound. Technique is simple, just shifting it posteriorly, anchoring it down. If you can do a rotator cuff repair, you can do this very simply. Early clinical data, again, Al's going to talk about how's it compared just to doing a partial rotator cuff repair. Is it any better? Will you get the same result? Maybe they're going to be the same. Maybe whatever we do, 85% will have a good to excellent result, whether you just decompress, whether you do anything. And should you leave the bicep intact distally? And so that's something that I've incorporated. Initially, I released it because I was worried they'd have bicipital group pain. And now I leave it intact and just shift it back. Results have been pretty much the same, no increase in pain. So thank you for your attention. And I apologize for having to duck out. But I know you're in good hands. Thank you. Have a safe trip. Yeah. All right, thanks very much for that talk, Sarah. So can you pull up the partial repair talk? And before we do that, so who regularly uses the biceps tendon for a irreparable cuff tear in this fashion, as somewhat of an SCR? OK. And who uses it for an augmentation for a rotator cuff repair, like Dr. Field had described? So if you asked that question maybe a couple years ago, I'm not sure you would get that many hands. And maybe two other questions. Who leaves the distal biceps attached and does not take it out? And then who detaches it and flips that over? OK, so interesting. We'll talk a little bit more. Hopefully you can go through the cases at the end, and we can talk a little bit about what we do and how we think about this. So I'm tasked of telling you guys about why we really should be comparing everything to the simple things. It's not as sexy, but it's debridement, bicep surgery, partial repair. Potentially why that's the most cost-effective thing, why we potentially should be using that as the gold standard to really compare everything against. Now, this is the way I think about irreparable cuff tears. I think about this category of patients where we know you have true pseudoparalysis. And when I say we know, when you see it, you know it. There's anterior supraescape. I think, in my opinion, when you see that, I don't really think it matters much what the x-rays show at all. What hematograde does this really, you know, what hematograde is it? Does it really matter? You're probably not doing much except getting a good outcome with the reverse. What if you have this other issue? So you just have isolated pain. So you have excellent function, but you just have pain. And you have very little sort of cuff arthropathy. Hemato-1, 2s, or 3. No glenohumeral osteoarthritis. What options here are really available for this? I would contend and argue that all options do pretty well in this. So if you look at any systematic reviews looking at this, and this was a consensus paper by the Massive Rotary Cuff Group with ASCS, all of these studies demonstrate that essentially all of these treatments did better than physical therapy. And then this is an older study that came out of the Mayo Clinic. When you look at sort of these options, what is the grade of recommendation for these? It's C. It's kind of like neither for nor against, right? Poor quality for or against. So any of these could potentially work. And then a little while back, we did a systematic review with one of my partners looking at over 3,000 shoulders, looking at 83 studies. And what did we find? Actually, debridement did the best out of all of the options. Now, it did have the highest conversion to a reverse replacement, as you might expect. But in terms of all the patient-reported outcomes and how they functionally do, debridement actually did the best out of all the available options. So what's a partial rotary cuff repair? Of course, we know this, and we see it. You can repair what you can. Often, this is the posterior infraspinatus. And then Burkhardt had described sort of this margin convergence where you basically try to restore the force couple or the bridge system for force transmission. What are the pros and cons and benefits of partial repair? Well, you'll know what these are. Relatively fast procedure, good PROs, cheap pain relief. Cons, potentially high rate of re-tear, progressive cuff orthopathy, and a lack of a complete footprint coverage. If we look at systematic reviews looking at this and debridement and decompression, actually arthroscopic debridement in comparison to these, tuberoplasty, bicep stenotomy, is actually a relatively good procedure for achieving good functional outcomes and good pain relief, actually, over a durable outcome. If you then compare it to partial repair, actually both cohorts do quite well with the arthroscopic partial repair probably leading to slightly better functional outcomes, despite the fact that the structural failure rates are high. There actually have been multiple studies and that's a midterm and even longer-term outcomes. There's actually sustainable outcomes with patient, in terms of patient-reported outcomes, sustained functional outcomes even with a partial repair or margin convergence. This is a more recent, this is a relatively recent study from arthroscopy demonstrating just that, good patient-reported outcomes even with partial repair to your follow-up. And then, you know, the French have been describing just cutting the biceps away, and maybe that's all you need. Cut the biceps, pain generator gone, maybe doing just as well, and maybe everything else is really just too fancy and unnecessary. So then there's this next category, and this next category, I think, is the most tricky one, of which I think this is where all the controversy is, right? You have a mixed picture of pain and functional loss of varying degrees. And the factors I consider when I'm trying to really think of what to do include what the age of the patient is, the degree of arthritis, what your ultimate goal of surgery is, the durability, and what's the risk tolerations of the patient. Ultimately, when I'm considering an indication for reverse, I'm really thinking about these type of things. Is the patient of advanced age or cuff arthropathy, regardless of their function, do they desire a one-and-done sort of durable procedure? And then be careful if they have external rotation loss, particularly if they have that in isolation. You're not solving that, I think, with anything other than a tendon transfer if the indication is appropriate. A reverse is probably not going to solve that issue. I'm gonna talk a little bit of SCR. I know, since we aren't really talking about it from our other faculty here, but this is still a procedure. I know it's losing less steam as time goes, but what are the pros? Pros are maybe you can get, from a cadaveric standpoint, functional superior stability, but the cons are you can't restore external rotation, it doesn't necessarily restore in vivo kinematics, it's time-consuming and expensive, and there's concern still regarding what the long-term durability of an allograft is. Is there a difference between allograft and autograft? Probably not much, as we think. This is a systematic review at Rush demonstrating potentially similar outcomes with both allograft and autograft. Initially, we were very interested in looking at whether this actually restores in vivo kinematics, and so we did an in vivo study looking at 10 patients pre- and post-op at one year who had an irreparable cuff tear, had an SCR, and we wanted to see whether or not it actually restored the kinematics and led to a less superior contact path, and this is a testing apparatus that we used for that, biplane fluorography, and then 3D modeling with the CT scan, and then you can really look at sort of what the contact paths are, and what did we find to our real amazement? The SCR patients, even though they did very, very well from patient-reported outcomes, actually did not have any change at all in either their in vivo kinematics or static or dynamic acromiohumeral distance. They didn't have any changes in their contact path or the scapulohumeral rhythm, so it really did nothing to change their kinematics, yet they all did very well from patient-reported outcomes, and this wasn't even associated with graft healing as well. The graft also stretches significantly, and so another study we did from that work was understanding that even in sort of physiologic ranges of motion, as the arm goes into adduction, the graft actually stretches way beyond what you would consider as a normal physiologic elongation rate. So based on those studies, we kind of thought, well, what does the SCR actually do? And in my opinion, given the lack of any changes, it's probably a pain-relieving spacer, which then leads to this question of what Rafi Mirzain has published and talked about, which is the tuberoplasty, and we're not gonna talk about that too much here, but it just leads to show you that there's still a lot we don't truly understand of how, why certain things work. In our further studies, the patient who I think benefits from SCR is a patient who has pseudoparesis. If they have elevation to about 90 degrees, and that's their only functional limitation, they'll have advanced arthritis. In our study here, comparing to marginal convergence, that is the patient actually does well with an SCR. Marginal convergence does equally well to an SCR when the patient has well-preserved forward elevation, and those findings are also corroborated by Peter Millett, who essentially demonstrated the similar findings, and even said the SCR had lower survivorship in comparison to a margin convergence. Cost effectiveness, John Sperling, a group at Mayo, has looked at this. SCR is actually way more expensive than even a tendon transfer or a reverse total short placement, so again, cost is an issue, and if you have similar outcomes, this is a consideration. Should we really be doing the SCR if we're having a patient who has well-preserved function and just has pain? Not gonna go over this too much, but tendon transfers, as Eric is going to talk about, with his lower trap, but as he'll show, this requires some technical training, and I think that's sort of one of the major cons, and there may be some questions regarding whether or not it leads to progression of osteoarthritis. Now, if you look at comparisons with LAT transfer and partial repair, there is a study looking at this, and surprisingly or maybe not surprisingly, arthroscopic partial repair actually did just as well as the LAT transfer. LAT transfer versus a partial repair, or a lower trap transfer versus partial repair, not a lot of studies looking at this currently, and maybe functional outcome scores are superior with the lower trap transfer. And then last, I'll kind of talk about this subacromial balloon, since we won't talk about this too much as well. Obviously, this has gained some popularity. There's questions regarding sort of what the long-term durability. In vitro, yes, it restores superior translation. What about in vivo? And then we all know this study from JBGS, which was a multicenter single-blinded RCT, essentially demonstrating non-inferiority of the balloon compared to partial repair, and actually durable outcomes even at two years after the balloon has biodegraded or dissolved. We also know this study as well, which is the Lancet, and this study basically demonstrated that the debridement was far superior to the balloon. And I would just remind you that the impact factor of Lancet is 79, as opposed to the AJSM impact factor, which is our highest impact orthopedic journal, which is about six. So again, the people who argue for balloon say that this study did not group or indicate the patients correctly for it. But again, the literature is out there that there is mixed results with this, particularly in a journal with a significantly very, very high impact factor. So, I think, what are the conclusions? Everything is still clear as mud, in my opinion. So, full motion and pain as your primary complaint, I would say don't forget about the simple things. Debridement, partial repair, margin convergence. I think you can still get an excellent outcome, as demonstrated by many studies, including our systematic review. True pseudoparalysis and your superior escape, I don't think that's improving anything other than reverse. If you have a mixed bag of pain and functional loss, I think you're younger, you have minimal arthritis and pseudoparalysis, consider options like bridge allograft, even potentially SCR, maybe even a balloon in an older patient with or without advanced age, with desires one and done, maybe reverse. And if external rotation is your main problem, isolation, I would say probably a tendon transfer is gonna be your best bet. But really, the main question is, are we really comparing apples to apples? And are the newer options better, or even more cost effective than just a simple partial repair? And I think the take home point really is, if we compare everything to this gold standard, I really think that higher quality comparative studies in which we're comparing the same cohorts are necessary to understand what the ideal indications are and whether they're cost effective, durable options. Okay, thanks very much. Oh, okay, it's Ivan Sok, actually. Okay, so we'll talk about allograft bridge augmentation disclosures. Thanks very much for having me, by the way. So we'll talk by the end of the session, you'll be better familiar with a bridging reconstruction, why it is better than partial repair, this is a great lead up to this, why recreating anatomy may be better if you can get it to heal, and how bridging can protect the remaining parts of supra and infra muscle bellies, and how you can get it to work for you if you so choose. So how do we typically repair cup tears? Well, we actually just heard all the different things, so I don't need to go through this. I agree with Albert, partial repair should be the gold standard. This is what we should be comparing it to because research is really how we're going to guide where we want to go. And why do we talk about this? Well, Steve Burkhardt has actually told you that maximum repair, you want to recreate this suspension bridge phenomenon. So you can see here the two bridges, as long as you have the rotator cable, it should still function. That's what we want to recreate. The problem with it is, is that when we repair this, we get a very high failure rate. So we don't get what we want it to do. So what can we do? We talked about RSA for those pseudoparalytic with arthritis, those that have acute or have good function with things we can do a primary repair. But those that don't have arthritis, that don't have fully atrophy of the tendon, those are the questions. These tend to be the younger patients, the higher demand. What do you want to do if RSA is not the right thing for them? I was lucky enough to do my fellowship with Steve Snyder and his team down at SCOE. And this was actually the very first case I did in fellowship and honestly learned a lot during that time. But the question is, who's our ideal patient for this? So this is a 45-year-old firefighter. He's also a professional bodybuilder. He injured his cuff and had an arthroscopic attempt at a rotator cuff repair. They couldn't get it right to the tuberosity. Then they tried a mini open at repair. They said it was non-mobile, non-repairable. You can see the size of the tear here, but he has good muscle all the way through. So some of our fellows, if you ever wonder about this, we have actually several fellows doing Vumedi things, so to be able to guide you through kind of like a 10-minute view of how this goes. This is a quicker view to look at it. So view from posterior portal, you can see it's all the way to the glenoid rim. If we view it from the lateral portal that you can see, we can see that the tissue as we pull won't even get to halfway to the tuberosity. So this is quite worrisome for a tear. I always leave the biceps. I do an in situ biceps tenodesis, so this is the anterior anchor go right underneath the biceps. I tenodesis it right in that spot to get that tissue just like we talked about. So there's a combination of those repairs. And then it's all about suture management. So we have multiple sutures essentially attacking it from every single angle. And so it's just a straight passer. I can get straight passers with three sutures in the posterior portal you can see here, three sutures in the visor portal or medial, three sutures for the posterior portal, couple the goalpost anchor, so it's like fixated to the tuberosity. And then we pass the graft in. And because we have sutures pass all the way in with stick knots, all we need to do is tension each of these sutures to get the graft to lie down nice and flat inside the shoulder. And all we have to do is tie these in sequential fashion. And then you get the reconstruction, that bridging reconstruction. And what you see is our clinical outcome. He got him back to motion. So he got all his motion back. You can see his muscle still is there. His external rotation doesn't come back to normal. But when you look at him, his range of motion or his external rotation on the other side is actually not normal either. So this patient is actually very happy. This is two-year MRI. You can see dermal graft doesn't become normal tendon, but it does stay intact and it does reconnect it. And we watched him and his muscle maintains. It doesn't get super big. The muscle that died is gone, but it gets maintained and the patient's actually very happy to continue on with it like that. So I really do think if you have supra and infra tears, that you don't have much arthritis, that you still have more than 50% of that muscle belly in those muscles, you can reconnect it. It's like a tendon transfer of the remnant tendons back to the tuberosity and you can get them to fire again. And the nice part is now we can compare them to other things. So we've actually looked at this. This is a randomized controlled trial study we published in AJSM, only impact factor of six, I get. In 2021, we compared maximal repair to bridging reconstruction. And what we found is when we get the bridge to the tuberosity, they heal about 79% of the time. When you do a partial repair, it re-tears about 80 some percent of the time. And we talk about the re-tear is from the anchor points that we fixated it to. So that did not heal to where you want it to heal. The partial repairs, because there's so much tension on them, I think they re-tear. What's more interesting is the chromosomal distance changes. So this is an example of those who did a partial repair. And what we found is that there's a significant portion, there's 30% of them that actually continue to progress Hamada grades to the point that there's no other salvage other than a reverse total shoulder. So partial repairs are not that you don't burn bridges. They can progress on while you're treating them that way. So why does bridging reconstruction work? I actually really wish, I'm hoping to work more with Albert Lin and his group, because they can identify all these factors that I cannot. But this is what I think. So I really do think Burkhart is right. Suspension bridge increases the function, but when you put a graft in there, that's actually where all the suspension comes from. We distribute the forces instead of from the two pillars, we actually pass it all the way through each of the suspension pieces of the bridge so that the forces are more distributed. So here's an example of this is Mr. SR, 69 year old gentleman, shoulder pain has full range motion, you know, muscles dying a bit. You can see some of it's gone there. There is a big defect from medial to lateral. This is what it looks like on the inside. Big defect, we're able to close it down. So do a partial repair first, tinnitus the biceps, get the graft in between to hold it in place. And you can see the tension of this to get that that muscle tendon working again. His post-op MRI two years ago, what you can see that the graft is still there. It's not normal looking tendon, but the muscle is also still there. It's not bigger than before, but it's not smaller than before. And our fellow here, who's actually just presented earlier on today, Dr. Prakashan, actually looked at this last year, did win, I think, the award here for it to show that the muscle belly is preserved postoperatively at the two year mark in both supra and infra. And so we're very happy to be able to say that, look, we can get it better. But more importantly than that, we're actually now starting to measure their strength. So this is actually one of the first studies we presented here just earlier today to be able to show that the patient's strength are actually increasing when you do a bridging reconstruction. So the muscle is actively working. I don't have all those fancy gadgets to do, but that's actually really important to be able to do it that way. What's the survivorship of something like this? Well, we find that over five year point, the work in dash for this definitely continues to improve over time as they keep working on the strength. We find that if they heal, they see continue to work that way. So 73% continue to heal as found by MRI. We can see that their muscle strength, we can actually continue them to because it's reconnected. They can continue working on that strength and keep getting stronger if they still work harder for it. And then this is the interesting part. Now we get to see what happens long term. So this is Mr. MF. He's three years after a bridging reconstruction. In Canada, we love hockey. So he dislocated it running into the boards playing hockey. So before the injury, he was actually completely normal. He's so happy. I didn't actually see him. I didn't think I'd have to see him again. The MRI, you can see the first part, the upper part, this is all the same series. The upper part, you can actually see the graft still attached to the native cuff and the tuberosity. But posteriorly, you see a gap. So his dislocation toward the junction between the graft and the native tendon. So this is a scope view. So you can see graft is on the outside towards the bottom. You can see the native cuff. You can see some vascularity growing between native cuff and graft, but very centrally, there is no vascularity. So this again, allograft doesn't heal fully. It just reconnects. That reconnection allowed him to function. And when you dislocate it, it allows me to sew it back together. How often do you go back for a revision cuff that you actually have more tissue than the first time you did surgery? How often do you get a revision cuff that I just got to re-repair the junction there? He had to look at other things. This is, it's stretching out. This is actually a bigger, I don't have time to show you all the things, but the first graft I put on is smaller than this. So there's no question. The data that Albert's putting out, I'm like, wow, I can actually see this. This is actually stretching out a bit. So it's not exactly how it is, but allows him to function. So what we did instead, we actually augmented on top. I don't know why it stopped, but we actually put another dermal graft on top to re-tighten it and allow them to function. So hopefully we'll be able to show you that bridging is better when the patient selection is appropriate. This does lead to good post-operative PROs, lower progression of rotator cuff arthropathy, lower re-tear rates, better maintenance of the chromohelm resistance, and now preserve muscle with increased strength. So I really do use this for those patients that have less than 50% atrophy of both supra and infra. And obviously, Albert's gone through a very detailed aspect of where we think each of these things can fit. Thank you. Awesome. Well, thank you all. I'll round us out. I'm Derek Widener. I'm at Emory. And I'm going to be talking about my use of Tendrance. You know, I think one of the cool aspects of this is you're seeing over and over again this idea that everything is partial repair, right? And when I'm talking, I'm talking about a partial repair plus a lower trapezius transfer. You know, Ivan clearly was talking about partial repair plus a bridging reconstruction. I think the partial repair without question contributes regardless of how much muscle is left. And then the question is, what do you do next? Disclosures are not relevant, but I'm going to sort of teach or talk to you about some of the different factors that at least I consider about when and why I do a lower trapezius transfer to augment my partial repair. So first, it's about the muscle. And we've been sort of hearing a little bit already about the muscle. This is an article that we just published in JCS on comparing our own institutional experience between the lower trapezius transfer and the SCR. And although there's more than just this table, this kind of highlights my view at least about why it's about the muscle. So when you look at guttality of 0 or 1, the SCR is actually doing pretty well. You could argue a partial repair plus an SCR. Maybe it needed the SCR, maybe it didn't. But it has good muscle. It worked all right. When the guttality was 2, 3, or 4, the SCRs did not do so well. And that's in direct comparison to at least my indications of when you have a guttality of at least 2, if not 3 or 4. You can see from a clinical outcome standpoint and from a failure and revision standpoint, the lower traps were equivalent to the SCRs when you had good muscle and much better than the SCRs when you had poor muscle. This is sort of reinforced when you look at this rotator healing index. Once again, it was all about the muscle. There's some other factors too, but muscles was the second highest factor on their sort of grading scale. And when you look at other things, the most relevant thing is that infrastenatus fat infiltration. This is the thing that's continued, comes over and over again. So when you have poor muscle, these partial repairs potentially don't work as well. And so from our perspective, at least from my perspective, what do you need to do to augment that partial repair and help make up for the lack of muscle? And latissimus without question is the one that has probably the most data. It's the one that has some near awards behind it and a variety of other Europeans presenting on it. But Joe Iannotti showed us almost over a decade and a half ago that 35% of his patients did not retrain. And when you look at the line of pull, it really doesn't make sense. Infrastenatus compared to latissimus versus lower trapezius, the line of pull makes a lot more sense when you're talking about lower trapezius as this is an in-phase and in-line transfer. And what I mean by in-phase is right now, my lower trapezius is firing. Right now, my lower trapezius is firing. Right now, my lower trapezius is firing. It fires when you elevate your arm. My latissimus is not firing when I'm doing any of these motions, or at least hopefully it's not firing. So we've published a couple of multi-stage trials looking at the outcomes of lower trap showing about a 10% failure, but in general, pretty good overall clinical outcomes. And conversely, we've also examined, and this is back when I think a lot of us were doing more SCRs, that when you had infrastenatus fat infiltration, the SCRs really did not do as well. And when you look at recovery curves comparing lower trapezius to latissimus or lower trapezius to SCR, it seems like the recovery curve is a little bit more sustained with the lower trap. And this is a recent one that just came out two months ago in JSCS. So we looked at all massive irreparable cuffs done where we did either a arthroscopic lower trapezius transfer or a reverse. So the normal scapular hemorrhism is about 2.5 to 2.8. When you look at what the lower traps got back to, they got back to basically a normal scapular hemorrhism. That kind of looks like a normal shoulder when you look at how much the scapula contributes versus the glenohumeral joint. On the reverses, these are all reverses done for massive irreparable cuff tear. So not cuff tear arthropathy, not OA. Their average scapular hemorrhism was 2.0. So they had, and you can see in this example, a lot of scapular compensation when you're doing this. So just as Ivan kind of showed you very, very elegantly how bridging allograft is potentially a little bit easier than you think, I would argue that lower trap is even easier than Ivan's technique. So I looked at my own personal learning curve. It was 14 cases. This is not a complication learning curve. This is a time, surgical time, the OR learning curve, and maxed about 14 cases and then sort of evened out. And I'll show you some technical tips that we highlight in this paper as well. So the lower trap harvest is probably the biggest thing that I think people get intimidated with. One of the biggest keys to this is making sure you sort of excise a bunch of the fat over the top of the muscle. And then once you've done that, then you can sort of take the muscle directly off the scapular spine. And as you can see here, it's a relatively quick, relatively easy harvest. Most of my fellows, after seeing one or two, can do it within probably 10 to 15 minutes. The one other kind of technical tip is preloading the sutures in portals prior to transferring the graft into the joint. This allows it to, when you have this nice thick, at least centimeter, centimeter and a half graft, Achilles allograft, it allows it to a lot easier to see when you're burying these anchors. And then you're going to shuttle the graft. I use a long hip arthroscopic grasper to shuttle the graft in. I use Achilles allograft for all of mine. I realize there's other options out there as well. But we're shuttling this in. And then once again, preloading those sutures into portals prior to actually burying it to allow you to visualize a little bit better. The humeral insertion, this is always a question, where do you put the anchors? I like to use four anchors in all of these. I start with my anchors on just, just behind the bicep or groove. So our first one's medial, the second one's lateral. The third one is a little bit more posterior. And then the fourth one is just off the articular surface. And so it creates this sort of box compressive effect down on the graft. The two more posterior anchors are with sutures that are preloaded on the graft about two centimeters back from the end of the crack out. And this kind of shows, if you're doing a biceps SCR that I'll show you in a second, the first anchor has a medial crack out plus the biceps SCR. The second anchor has a lateral graft crack out. The third anchor has a preloaded stitch and then the fourth anchor has a medial preloaded stitch. So if you're doing a partial emphasize repair, you can, uh, you can bury that as well. So this kind of shows just a really quick video. This is, uh, with the, the first anchor that has a biceps SCR stitch as well as the, uh, the medial crack out, you then are going to go to this second anchor that you're burying. This is with the, uh, lateral crack out. Then the preloaded anchor laterally, I'll, I'll, I'll retrieve it back and I keep it posteriorly until I'm ready to bury it. And then you're burying this laterally just off the greater tuberosity edge. And then you're going to go medial with the partial emphastinatus repair stitches, as well as that medially loaded stitch just off the articular surface. Um, then you bring the arm and maximum external rotation. You split the graft. I do one pulvertaft weave. So meaning I'm bringing the top through the actual tendon itself, and then I'm securing it with multiple stitches. Maximum tension is the, the, the, the key here is the allograft as, as, as, uh, Ivan just talked about. These grafts do stretch out. So I want maximum tension to sort of maximize my ultimate outcome with this. I'll do a, uh, um, uh, pulvertaft weave with that to create this sort of sandwich around the lower trap. And you can see the tension, um, when you're internally, externally rotating it. Um, I do do partial cuff repairs on everybody without question, regardless, fat infiltration, regardless, tendon left, I do try to bring the amphora over. I will try to bring the super even if it, even if it has a fat infiltration. Um, this is an example of doing a partial repair with a knotless mechanism. That's sort of more like a double row repair. You can tie knots, whatever it is you need to do to get some of the cuff down. I really strongly believe lower trap by itself is not near as functional as if you lower trap to augment a partial repair. And I think that's a really important point that's maybe missed sometimes. Um, this is how I do a biceps SCR. So I do detach them. So I tag the biceps just next to the articular surface. I wrap it around a couple of times and bring it back through the biceps. And then I'll do my biceps tinnitus is lower in the groove. So I like to detach them because I do worry about them having pain. It's clear that maybe that's not a, that's an unnecessary worry and maybe I'm treating my own neurosis with that, but nonetheless, uh, I, I sort of do, uh, do do this. So this is me sort of exposing the bicep or groove, um, once again, uh, below the bicep or groove where I usually do my, my tinnitus disease, I'm once again, tagging and then wrapping a couple of times around the biceps. And then you're going to see, I'm going to bury that into an anchor and then I'm going to detach it, or I guess I detach it first and then I'm going to bury it to an anchor. Um, basically completing my tinnitus, but then having the other search ready to bury for my biceps SCR. So this is the tinnitus part. And then this is after, um, loading the preloading, those stitches, remember that first anchor is the one that I'm going to bury with the biceps SCR. So I take the biceps SCR stitch and I take that first meal crack out on the, on the graft and I bury it just next to the bicep or groove, just next to the actual articular service. And then this is sort of what it looks like. So here's your graft, the partial repairs underneath the graft. And then there's a biceps SCR coming in where you can see it's sort of helping to support to maybe close some of that space that's still open and, uh, and, um, maybe give me some superior support. So it does seem to work at least most of the time. This is an example of a gentleman preoperative as shoulder subjective value. Um, you can see his scapular humor rhythm pre-op compared to post-op, a lot of scapular compensation. He sort of got rid of that by two years. Um, and you can see his patient blocker measures improved. And this is one that's held up for four years and you can see her scapular humor rhythm at four years. Um, and, and it's hard to tell even which shoulder we operate on in the four year video in the upper right. So once again, when do I do a little arthroscopic lower trap? You know, I really base it off muscle, at least in my mind. I like, um, I like it when I can primary repair that's the best without question. But if I have poor tendon, I do think you need to make up for this. I at least incorporate a structural graft into my repairs. If I have good muscle and poor tendon, I'll do a structural graft. But if I have poor muscle, I do think you need to replace muscle with muscle. And that's when I do a lower trap to augment my partial repair. I do think it works pretty well. So thank you for your time. Reach out to me if you have any questions. Awesome. Can we pull up my talk again? There's some cases in there. So as we kind of pull this up, I'm gonna ask some questions to these guys. So Ivan, in your technique, where does your technique lie in sort of, and I think you get such great outcomes, one, because you're looking at the muscle quality, because you were saying about grade two, right? And also because you do something to also restore the cable. And I wanna ask you, where do you feel like your algorithm rests with like some of grade three, grade four fat infiltration with the same type of radiographic parameters? Yeah, so that's always tough. Well, I actually like trying to figure this out. My fellows, when we try to measure this to figure out how much fatty infiltration or atrophy there is, I think we all disagree between 3 and 4 and 1 and 2, and none of us seem to get there. But when you get to 50%, lots of us, we're saying, is this less than 50, more than 50? We're much better at doing that. That's why I try not to go after that. When we tried to do this, we initially did this including grade 3 and 4. And that's where we saw the failure rate come higher and less strength. Patients were extremely happy in terms of pain relief and function. So they could do just regular against gravity, but they were not getting that much stronger. And you got to remember, allograft tissue is not like normal tissue. It doesn't come back, heal, and last forever. Those ones, because they weren't using it as much, they seem to fail over time. So that's why we actually narrowed the indication. We brought it back to grade 2 type of atrophy where they're actually using it. The more they use it, the better the outcomes when you keep going. Yeah, I mean, I think that's key. I think sometimes when people say, oh, bridging allograft doesn't work, I think they're often doing it in patients with grade 4 foul infiltration. And so you can expect you have no muscle there. It's not going to function quite the same. Eric, I wanted to ask you too. So somebody comes in, they have an irreparable cuff tear. They don't have a lot of ER lag, or maybe they have none. They have good motion. They have poor muscle. Is that a person that you feel like a tendon transfer is actually going to preserve their shoulder over time and are you looking at that as sort of a long-term outcome? Because some people might say, okay, this person can already lift their arm. They're looking for pain relief, and then you go through the trouble of, you show some really elegant procedures here, but is this somebody you think that they need that tendon transfer because it's restoring their biomechanics? Yeah, that's a great question. So a little bit loaded too. I mean, I don't think you should ever do surgery to prevent arthritis. I don't think a tendon transfer, to do it with a sole goal of actually preventing arthritis makes sense. We don't know if that actually happens. That's something that's very hard. And as Jed Kuhn talks about this, some people are just sort of these rotator cuff or cuff deficient people that have this natural progression. Can we alter that by putting in an allograft and maybe a lower cuff? I'm not sure. That being said, for me, if somebody comes in with decent function, but they have pain, without question, there's a whole wide variety of options. Now, what narrows it down a little bit for me is if they have pain, and although they have good preserved active motion for the most part, they have significant weakness and that's actually what's troubling them. I live in Atlanta. It's like the golf capital of the United States, it feels like. Maybe others could argue, but I mean, everybody wants to go back to tennis and golf. And that's, for me, if they're just having pain relief, man, there's a lot of options, including just the biceps alone. But if you're talking about pain and weaknesses, as Ivan was talking about, then that's when I'm considering doing some sort of reconstructive procedure. That's also something I definitely avoid doing any type of arthroplasty on, but that's when I would consider it. So somebody who has a significant weakness and the weakness is actually what's limiting them, that's when I think if their muscle ability would equivalent, I would consider doing it, yeah. Yeah, I mean, I love those fluoroscopic images you show. I mean, it's hard to argue against a procedure that actually restores your normal biomechanics. And so I think it's a sort of a theoretical dilemma where you say, okay, I'm gonna do this big surgery for somebody who actually has well-preserved function. So this is sort of case one here. He's a 72-year-old. He's a very active guy. Many years of symptoms. Now it's progressed to the point where he really feels like the pain is an issue. He's had years of physical therapy, probably multiple injections before he came to see us. And look at his exam. He's got good motion. He has no lag signs. He has expected weakness. Doesn't have a lot of Hamada changes on his X-rays. You look at his MRI, he definitely has a posterior superior cuff, which we could probably argue is this grade two, grade three, probably somewhere probably along the grade three category. And the conservative stuff has not worked. So I don't know, what do you think? I mean, do you think this is the kind of type of person that you would indicate for that allograft bridging? Yeah, so if you can just go back one, I think this is key. So it's not just imaging. So this imaging, when you look at it, I would say you're exactly right. This is somewhere between two and three. So when you start about two and three, now this is where the discussion comes is, do you think that this muscle is actually firing? And is there a way that we can reconnect it to get him strong? Because I know if you can get about 50% of the muscle, we can actually get a measurable increase in strength. Now I can get them at least 25% stronger, depending on what they are. So because he has full range, I don't just want four out of five strength anymore. I want a pounds per external rotation, abduction, forward flexion, and then we're gonna have a chat. If he's so weak at that point, then I would say, okay, you know, maybe that's not enough. Maybe just giving him a 25% is not gonna get him what he wants. So it actually is more quantitative than this, but this is definitely one that will have the conversation that he's a potential for a bridge. And then a follow-up question to this, if you're gonna sort of bridge him, and then you go in, and occasionally we see a patient go in, and we're anticipating doing some kind of a partial repair, like we can bring like the posterior cuff up, but in certain patients, like that cuff is, it's stiff. You can't bring it up. You can't restore any of the force couple, and you could try to, but we all know when it's not satisfying when we do it. What do you do in that case? You still like, oh, we're gonna abort from the planned bridge allograft, or are you gonna continue pushing forward? Yeah, no, that's a great question. So in terms of bridge, the nice part about our bridge reconstruction is you have some room to work. The grafts that come in, come in a five by five setting. So we actually go out to five. If I have to go out to five, I know that the outcomes are not quite as good. So in terms of the mobility, most glenoids and most grafts, we can actually get down to a three by three. And that seems to be the sweet spot, is three by three allows us to get good coverage, right? Good reconnection and tension for the graft reconstruction. So what we're trying to do in this case, if I look over here, his teres minor looks perfectly fine. His infraspinatus is the question. I bet you it's a full thickness tear of infraspinatus. Usually in that carrot, they scar down to a little bit of teres minor. I can get that to the articular margin. And if I can get that to the articular margin of the greater tuberosity, I know I can have a three by three to be able to get a bridge. Yeah, awesome. Eric, what do you think here? Yeah, I mean, so once again, the strength, I agree. The four or five, so my assumption is there's not much resistance. So if you're, and we've got these strength measurements, but I mean, if they really can't resist your strength measurement means that they have like less than three kilograms of strength. Like that's for me, it depends on their goals. But if their goal is to get back to active things like golf and tennis and pickleball and whatever else, and function, that's their main problem and not just pain. It seems like it is given their give their shoulder 20%. I think doing, I agree. It's hard to say, is it two, three? But I do think repair what you can, you probably can get back some of supra and some ever in this case, but probably we'll still have some defect and won't be a really satisfying repair. And then personally, yeah, that's enough fatty infiltration. I would do a low trapezius over the top. Can you like just kind of talk about how much strength can you regain from a tendon transfer? Yeah, I mean, so if you look at it, it's data outside of the shoulder, you lose a muscle grade if you transfer a tendon. That being said, this is not exactly transferring a tendon because you're just kind of rerouting it. Also, that's why I think the partial bear is important because I think by itself, the lower trap, although it has similar excursion to the infrasteneus, is clearly not going to be the same as a normal infrasteneus. So if you do it by itself, so in those that are completely white on the backside, meaning you have no infra, no teres and no supra, and you do just a lower trap and that's it, and that's all you have, you'll notice that the function and the strength is not much. Or if you do an plexus patient, the function, the strength, I mean, they can get back to neutral, they can get some extra rotation. It's not great strength. But if you augment it with a infrasteneus repair, this has teres minor hypertrophy, I think I could get this patient back to a very functional, relatively normal shoulder. That's probably gonna be 80% the strength of the contralateral shoulder. If this guy said, I want a one and done surgery, would either of you even remotely think about doing a reverse total shoulder placement in this person? I mean, for me, with 160 degrees of elevation, man, that's, with no arthritis, that is a, that's a little bit of a horn test, because you will lose, potentially lose some function. You will potentially create an unhappy patient, a T11 internal rotation. I mean, you know, if that's, if they really push you on it, you'd have to make, lay a lot of credit and be very clear. But I personally have had a couple very unhappy people that I have had that I've done reverses on with full motion and they didn't get back to full motion, although the outcome, from my objective standpoint, seems perfect for the reverse. They were not as happy. Ivan, you agree with that? I'd echo that. I don't do reverses, so I send them to my upper extremity colleagues. And I'll tell you, they actually send them back to me now, so if they have full motion, we can get a much more standard improvement with our bridge. Yeah, so I mean, what these two guys said was key. I think you've got somebody who has well-preserved, excellent range of motion that, if you look at any studies of reverse replacement, is the cohort that does the least best or the worst out of all the cohorts, primarily because a lot of times you're actually sacrificing motion and actually a patient can be quite unhappy postoperatively. But I guarantee you, though, if I show this picture, like this clinical scenario to the wide audience, there's gonna be tons of people who say, we're just gonna do a reverse total shoulder replacement. And I'm just saying, I think we have to be a little bit careful. So let's poll here, okay? So you have a patient like this, good motion, probably irreparable cuff tear, posterior superior, no lag signs. Who is doing a debridement partial repair plus or minus a biceps-type surgery? Okay. Who is doing a superior capsular reconstruction? Okay. What's that? With biceps. Okay. Okay, same thing, Guillermo? Fasciolata, okay. Can I ask you why? Yeah. One of the biggest differences with fasciolata, if you aren't familiar with it, is that in the described technique with Mahada, he placates it multiple times into almost four layers. That actually achieves almost a seven to eight millimeter type thickness. And if you think about it, that essentially is somewhat of a spacer. It's a biologic spacer. And so who would do a subacromial balloon in this patient? Okay. Who's gonna do a tendon transfer in this patient? Bridging allograft. Okay, so what did we do? We did pretty much, he had a little bit of subscap tear, so we fixed that. We tenidized his biceps. Probably, this was many years ago, I probably would have used the biceps to do a debridement. We simply did a margin convergence. That's all we did on him. This guy did excellent. He still had obvious weakness. And I think this belies sort of the thought of really understanding what your patient wants. And if the patient is really unhappy because of weakness, then I definitely think the conversation regarding what you can do to restore that, and Ivan's showing us a lot of good data that you can improve our patients with bridging allograft. And Eric has demonstrated the same thing with his partial repairs and his tendon transfer. But he, I think, really wanted something to be out of pain. And this achieved a very, very good outcome for him. And he went on to do the things he wanted to do. But it goes to show you, for many of the same, for this scenario, you can see sort of how tricky the treatment options are, given sort of what the responses were for all of those options. All right, second. I was just gonna say two comments. One, the comment on the fasciae latae, you know, it's interesting. When I was doing more SCRs and they would tear off the glenoid, patients would still have maintained some aspect of pain relief and maybe lose a little bit of function, a little bit of strength, but it didn't seem to be as drastic. You know, when I have the lower trap that tears, it usually tears off the humerus and retracts back. So it doesn't stay in the joint. Those patients do significantly decline when that happens. And so I do wonder the spacer effect, as kind of your point, that even with the little skinny one, not the fasciae latae, but the little skinny dermal allograft, I did see, even when they tore off the glenoid, there still was some aspect of relief that I do not see when the tendons fail and when they pull off. And then second comment on that reverse. You know, there's some really nice studies, Hartzler, Gulotta, a couple others, that really highlight how unsatisfied these patients can be with good function. And you know, it was interesting, Gulotta study, if you look at the details, they actually have like a little illustration form and all this stuff that they showed the patients before surgery about what their expectations were afterwards and yet his patient still had significant issues. And you know, random story, but one of my friends, not one of the surgeons who it was, but actually he's gotten sued for a reverse that's fully functional and the patient was claiming that they disabled him because he lost motion from their actual pre-op thing. Clearly it didn't actually work, but just shows some of these people with full function, especially at least in Atlanta, the ones that wanna get back to like yoga and Pilates and all that stuff, you gotta be really careful. Yeah, I agree, that's America. Can I add something else? So the SCR, so SCR with fasciolata is actually very different when you work with Mahada because we just did a lab together last week and watching him put together his graft, it's not like our dermal grafts, it's not this floppy thing. It's not only does he put three layers together, but he puts so many stitches in there. It's probably 70 stitches that he actually puts together. And this thing, you can actually take it and it will stand completely sideways. It is so stiff. This is not the same thing that we do in North America. And when he does this, he actually sews the muscle back in here. So again, the operation is completely different than what we have actually done or we've changed his operation to do. I really do think these things are very specific to what we wanna do. And that said, this actually shows exactly what you just did. You did a partial repair and that really truly is the thing. If you can get that to heal and you can get that to function, they can maintain and be very happy. It won't change what we do because you're not connecting more muscle to it, right? So I think it's still a very, very good operation. And depending on your different skillset, experience, what you're comfortable doing and what the patient wants, you're gonna be able to make a very educated guess on what's gonna be best for them. Yeah, great, great points. So let's try to see if we can get through two more cases here. So a 49-year-old, he's a carpenter, acute on chronic pain, he had a fall. He's not able to lift his arm very well. He's got pain, he's got limited function. So this is dealing with a different issue now. So this guy's a reasonable size, 5'10", 180. His elevation is about 30. He has full passive motion. He can maintain that position if you get him all the way up. He has no external rotation lag and he has three out of five for elevation strength. So this is the way he is presenting here. Okay. These are his x-rays, which I won't fool you with anything. I don't see much on here. And these are sort of some spot images on his MRI. So that's Eric and maybe Eric, we'll start with you. Yeah, so do you mind going back? What was his external rotation, all that stuff? It was normal? His ER was normal. Yeah, yeah, okay. So for elevation normal, external rotation normal. He's weak and painful, clearly. Correct. And he's pretty, he's young. Anyone who's relatively my age is young. Yeah, fair. Fair. So yeah, on this, he clearly has a posterior superior tear. It's retracted back, tendon length. It's hard to say how much tendon's left. And he has, you know, super interesting enough, it's not as bad of a fat infiltration as super. That retraction, I think that you're seeing, but there's some muscle belly there. You know, it does look like there's some fat infiltration in the infra. Once again, it's a question of two versus three. And then you have a very hypertrophic tears in this case. So, you know, this is an interesting one where I think you're right on the borderline, at least for me, whether I'd consider doing a structural allograft to augment the, like repair what I can and augment it with a structural allograft versus doing 10-transfer. Because once again, super doesn't have that much fat infiltration. And you could argue the infra does have kind of that borderline. So I guess I'd assess him from a functional standpoint a little bit more and especially from an external rotation standpoint. And I guess I get a sense for what he's trying to get back to, but I think this is one of those that it'd be kind of on the fence. I probably would end up doing a lower trapezius transfer, but I, you know, if he has a relatively preserved function and I looked at it a little bit more and there's actually decent muscle in the infrasense, I could see the argument to doing a structural graft on this. So let's say you had the plan to try to repair him, like you've mentioned, and you can only do a single row repair. Will you still try to augment that? So yeah, any of these massive cuff tears where I have a really bad, poor quality, I'll do the biceps SCR kind of like I showed. I do detach it. I realize that nowadays a lot of people don't detach it. And then I will tie a graft where I bring my, I try to do a double row or if I'm doing a single row, I'll bring the sutures through that are coming through the tendon, through the graft. And then if I tie the single row repair, then I'll bring those to the graft and I'll bring the graft kind of laying over the top. So not an interposition, I'm trying to get the cuff back down to the footprint, but in essence, like covering the footprint with the graft. And so basically bridging it from the, or spanning it from the muscle belly to the actual footprint. It's interesting, I know Catherine Burns is doing a study that's somewhat similar to that where she's using putting like a tuberoplasty and then with the medial row anchors actually fixing the tendon in a single row fashion and see if all of that sort of melts together. So it's probably kind of sounds a little bit of a similar concept. Ivan, what do you think here? Yeah, sorry, is this an acute tear? Is this what's going on? Sort of like acute on chronic. I was gonna say, just because something looks very odd, there's a lot of swelling, a lot of edema in that muscle. So there's some kind of acute component to this. The other thing that looks really funny, if you look on the axial views there of the infraspinatus, the posterior area, I don't know if you have an arrow on it, but you see this waviness on the infraspinatus. So I actually think that that infraspinatus is more acute or at least that part of it. So I think that the muscles actually retracted more, you have more tendon on that. And that would kind of explain why it looks like there's more atrophy in the sagittal view on that infraspinatus muscle. So I think there's actually more to this. This person being that young, I tend to, anyone who looks younger than I feel, I would want to be more aggressive at trying to fix or reconstruct this. So like Eric, I do think that we probably can get this back onto the medial footprint or even medialize it by about five millimeters, get most of it done. Because my partial, again, that starts off, the very first thing it starts off is partial repair. Repair as much as physically possible. And hopefully get that even less than a three by three. Because the smaller I get, the even better outcomes they get and the stronger they get afterwards. Does this guy's exam concern you in any way? Like his really his inability to lift? You think that's pain mediated? Okay. Yeah, so again, the swelling there suggests the pain mediation. That's why I just did what this acute or not. If I was concerned or I'm worried, because right now you just told me that he's passively getting full. He doesn't have frozen shoulder. MRI has no concerns for something like that. I don't see anything else going on other than pain mediated because of the swelling in. If I did, that's where this diagnostic injection would help. If it took away his pain, all of a sudden he actually moves better. It would again suggest that we can repair this. All right, so the case summary here. He's a laborer. He's got supra-anter-infra. He's got functional, probably what I would say, pseudoparalysis. I would not say that this is anter-supra-escape. No significant arthritis. No real Hamada changes. So let's kind of pull again here what we would do here. So vote for partial repair versus full repair with the use of a biceps. Okay, and then what about tendon transfer in this case? Mike? What's your thought with the tendon transfer, Mike? Oh, O'Brien. I think that it's gonna be worse than you'd expect. And I think it's too non-chronic. I don't trust that interest changes. So I'm gonna do like Eric suggested and repair the whole thing and still add a lower cuff. Nope. So you'd be prepared to do it if you need to. Or you would just do it no matter what. Okay, how about a SCR? Okay. Can I ask Mike the question? Yeah. Do you ever worry in somebody who's young about taking the trap off? Is there consequences to do a lower trap transfer? Yeah, that's a great question. So the function of the trapezius, obviously, in addition to just shrugging your shoulders, the main function of the trapezius is actually a scapular external rotation, right? And so that's why if you get a paralyzed trapezius, you have this kind of lateral winging and translation, but lack of external rotation. And that's why people get impingement. That's why people are limited, especially in abduction. But it's the external rotation. The external rotation is really driven by the upper and middle trapezius. Lower trapezius really acts as a compressor to the trapezius and kind of stabilizes it and acts as a pivot point. So by moving it, you're still giving it that compressive effect. You're not taking away the external rotation moment arm of it. You're just basically maybe taking away a little bit of that stability, but it's still compressed over the top of the scapula. So biomechanically, it wouldn't make sense why it would have residual effects, and I've never seen any residual effects. I have to say, I've not seen, at this point, almost on 200 of these, I've not seen a single person get scapulothoracic bursitis, which would be, in my mind, the hallmark of somebody who's having some sort of scapula biomechanical problem. So it's good. I don't see a downside to doing it. In this guy, where you're not doing it, it could be a downside. That's my opinion. Yeah. And it would be, well, I have the chance. Awesome program, by the way. So thank you. So a few more. Balloon. Any balloon takers? Bridge allograft. Reverse. All right, good. So this was a number of years ago, actually. Probably maybe seven or eight years ago, and SCR was sort of in vogue. And he was a young guy, and we did the biceps tendinitis, and that's what we did. Actually got in, and exactly what Mike O'Brien just mentioned, infraspinatus actually was quite trash. It was very difficult to actually pull anything into the joint. So we did an SCR on this guy. And I'm not sure I would do that now, to be honest. I don't know. But that was sort of the option. And this guy did phenomenally well. And so it just goes to show you, you have your treatment algorithms, what you're trying to accomplish here. I think I would have entered this with the same kind of option of partial repair using the biceps as sort of an SCR, since it's there. Nonetheless, this guy actually ended up recovering a good deal of his strength. It's not perfect. But he did very, very well with the SCR. Now, since last time follow-up, he probably has gone on to a reverse replacement. So. Could you repair the supra in this case? Was the supra that bad and retracted? Yeah, I couldn't repair a supra. But I did repair it. If you look at one of the, I think, let's see if I can go back. Your infra and teres came onto the graft. Yeah, we were able to repair the infra and teres to the graft. And we were able to prepare the stump to the medial row anchors on the glenoid, which I think actually helps if you're doing an SCR. But it's hard to know. And I think the more I feel like with this topic, the more I learn, the less I know. So I want to get to Ivan's case real quick here. I've got a million cases in here. All right, Ivan, you want to present this case? Oh, god. If I can remember this case, you probably know it better. It's a 52-year-old gentleman, Canada, snowmobile accident. Had a cuff repair that same year. And then had a motor vehicle crash two weeks after surgery with another repair. So he already had two surgeries. Two weeks after the initial repair. Yeah, that's rough. Yes. So he's had a rough time already, unfortunately. Icy conditions in Canada. So again, this is a failed rotator cuff. Massive two tenon, hopefully you can see there. There's anchors in there already. Exam, he's similar to a pseudoprilate, right? So foreflexion only to 90, abduction to 45. External rotation, he still has some, 30. His strength really is just, you just barely push on him, it goes away. But passively, you can get him everywhere. This is tough. Eric, with this being like an acute injury, would you even attempt to go back in and re-repair this? Or is this like, OK, we're going to leave this be and do something else? At some point, it's like the definition of insanity, right? Doing the same thing over and over again? Yeah, I mean, so clearly he doesn't want to heal. This tuberosity is going to be really anti-healing, meaning that you have anchors, you have clearly a lot of scar tissue. You're already up against the wall, and you're going to be really up against the wall trying to get this to heal a third time. And as we know, revision repair, open or arthroscopic, the outcomes are mixed, especially in the massive. The small revision repairs, I think, work especially with some augmentation. The massive ones, and this appears to be a massive one, it's sort of a flip of a coin on how well they work. So from my perspective, when I have a massive repair and they're, in my mind, a candidate for something other than a reverse, I have to do something different than was done previously. It sounds like they had just two primary repairs, in that case, correct? Yeah, just two regular primary repairs. So in that case, what I would say is I either have to add in some sort of augment, and that could be a structural graft, or that could be a tendon transfer. In the case of two prior repairs, I can't see the quality of the infrared, but my assumption is there's probably some aspect of impact on it, and the tendon quality is going to be poor. I'm going to repair what I can again, but without question, and as I kind of mentioned, although you might be able to get it back, you might be able to be somewhat satisfied when you're done, I'm not sure if I'd be as satisfied adding another sort of dead piece of tissue on top of an already poorly healing graft and so from my perspective, I'd want sort of a dynamic backup to this, and so most of my revision mass of cuff tears, I do a lower trap on. Yeah, but well, let me ask you that. So when you do a tendon transfer though, you have to attach it to allograft, right? So okay, so I contradict, okay, fine, I contradict myself, fair. So I guess my point was that I'm already worried about the cuff elasticity and how well it's going to be functional. You mean having something dynamic. What I meant to say is I want something that is going to be dynamically and sort of native. So I'm creating a new muscle, giving a new muscle to sort of augment that already kind of twice operated on a cuff that hasn't healed yet. Would either of you guys do a biop, like a arthroscopic biopsy for an infectious workup for something like this where you have two procedures and what's your threshold for that? Sometimes we have patients coming in with three prior surgeries. To be honest, I do it and I do it on occasion, but I really have never found any of them to ever come back positive. So I don't know, what's your guys threshold for doing like assessing that? So I'll do aspirations and usually in this case, maybe not because it seems like it was relatively acute falling each other, but if there's something at all that tips it off as MRI, if there's something on the MRI that looks like it or there's something multiple surgeries that sort of fits and there's maybe a little bit of pain is out of proportion, I'll do aspirations. I don't know if I, I do arthroscopic biopsies for implants just because I don't think the aspirations are as useful, but for this native shoulder, I still think if something's there, I do an aspiration. But I agree with you, it very rarely does ever show up in anything. Yeah, no, I completely agree. We actually tried to do a bunch of those samples to go out. Number one, our infectious disease area actually mix all the samples together so I only get one sample coming back and then half the time they tell me they didn't grow anything in two days. They didn't follow that two week option. So again, hasn't been useful. So Ivan, do you wanna just take us to what you did here? Yeah, so this may not be exactly what everyone else has done. So went back in here, I wasn't a part of that first one. We went back to assess and when we're looking at this, this is again, just try and look back forth there to see how that tissue is, where it looks. It did look like a tear, it looked like a scarred down. So if you're looking back here, that tissue looks like it's scarred down to the both just underneath the cuff and superior to the cuff. And the tissue actually looked robust. So that's part of the assessment that I would go for. How long it's been is again, we tend to use this graph that way. How long it's been and how much it can pull is the other thing to look for. So this is the posterior aspect of it. We try to see how far it can get up here. So there's only the teres minors is still there. And you can actually see where infra is actually scarred down to teres. So this is what we're talking about. We can usually bring that up a bit more. So again, we may not choose to do a bridge, but once we decide to do a bridge, we prepare it on the back table because it adds a few more minutes. And then once I have that tissue, you can actually see where that tissue is. In the back, it's red, it's edemonous. You can see where it torn, it's scarred together. It's actually got good enough bite that I could actually bring that tissue together. And the further I grab it, the more tissue actually wraps around to decrease the chance for a tear out the tendon to suture area. Only problem with this is, only question for me usually is, is this going to be too big? Because I don't want it to be too big to have a higher chance for tearing. And the sequence of steps in this case, this actually was bigger than usual. You'll see a lot of different sutures in here. This has got to be that way. So again, after choosing this one, I probably would have at that time, this was quite a while ago, I probably would have gone to a lower trap for something like this. My only trouble is the bridging. When I do something like this, I don't usually have trouble getting it to heal from the cuff to the graft. I have a tougher time for it to consistently heal to the tuberosity. And I have the same problem when I do lower traps. And again, I've spent a lot of time, I do want to ask you all these kinds of things. Sometimes I've been told, look, the lower trap can heal for the very posterior aspect of tuberosity. It still has the function, it's good enough. It just doesn't look as good on the MRI because it doesn't heal exactly where I put it down to, but that's the same problem I have with my bridge. So, Ivan, it's easy in America, we just don't get MRIs post-op, so. I know we're out of time, but Ivan, one of the hardest parts about that type of case, and I know when you were shuttling the sutures in, I heard a snicker in the audience because I had the same thought. You know, when I do these structural grafts, I mean, the suture management is like the hardest part by far. And that's why I'd argue it's harder than the lower trap. Can you talk just a couple of quick tips on how do you make it look like that and not have, those who are fly fishermen in the audience, like a hornet's nest that you're trying to cut off your flies to try to get untangled? So, absolutely. I'll tell you, this is the very first case that I get to go do with Steve Snyder and it scared the bejesus out of me. After he teaches you the technique of not to tangle, it doesn't matter if I have one stitch or 30 stitches through a cannula, you don't tangle them because essentially all I do is, it's a straight shoot. It's a medium crescent. It's the easiest possible instrument to use. It just goes straight. So I start off my anterior portal. I punch through the biceps. I go in the lateral cannula. I grab it out. I pass the suture through. Then I go slightly posterior to it. Every time I go in with my grasper to grab that suture, I go posterior. I have my finger on the remaining sutures, pushing them anterior. I take the other half of the cannula. I put my grasper to go in posterior. If you follow that all the way around, it doesn't matter if it's 12 times, 15 times. I think this was a 16 suture pass. It's the exact same thing. It is just tedious. And I think my fellows still here, they know this is the least favorite case I do have. So again, I only do this because I think it does better for the patient. It is the hardest complicated, like it is definitely harder. I would prefer to do a lower trap because I can consistently do that with four anchors to go through. This is less anchors than that. So it actually costs less, but there's a heck of a lot of suture management. But once you get the suture management, the nice part is you can do all kinds of things with it. So the augment on top, those we do all the time, it's only six sutures. They become easy. Everything else becomes easy. This is just the hardest one. Amen. Any last questions or comments from the audience here? All right. I really appreciate your participation in here and I really hope you guys have a great rest of the conference. Thanks so much.

irreparable massive rotator cuff tears

superior capsular reconstruction

Sara Edwards

Albert Lin

partial repair

tendon transfers

subacromial balloon

allograft bridge augmentation

lower trapezius tendon transfer

muscle quality

surgical intervention