Welcome. Wow, 7 o'clock in the morning, and someone beside me got out of bed today, which is, if you all know me, I don't do well in the morning, so this is impressive. Anyway, we have a great panel today, and we're going to talk about rotator cuff repair, starting simple then going through revisions, and then Jeff's going to talk about how he augments some of the options out there on the market, because it's so many now that it becomes somewhat almost difficult to make that decision. And then Basam is going to talk about his methods of when we don't have power, how we can bring power back to the plate. So Mark Edelman's going to start us off first with his approach to rotator cuff repair. Thank you, Mark. Good morning, and thank you all. If nothing else, I'm just excited to be part of the best dressed faculty on instructional course lecture at 7am. I had to get up early to try to compete with Basam and Jeff. It's not very easy to do, so thanks for the opportunity. So we're going to start talking about the basics, and we're going to continue on up. When we think about the rotator cuff, there's lots of things that we consider, but understand some facts that are really indisputable. There's this avascular zone in the rotator cuff that is about a centimeter from the insertion site, and your breakdown of your rotator cuff as it starts to fail occurs in this avascular zone. And the avascularity precedes the problem. It's not the result of degeneration. And then once the rotator cuff tears, there's changes to the muscle penation angle that are critical to understanding how we're going to manage that patient. And then we still have controversy today. They've got me on the main program at 8.30 talking about single row versus double row, and we hear about industry pressure and peer pressure, and it's still a challenge to figure out what's the best way to do it. So very quickly, my double row indications are very, very narrow. An acute traumatic tear with no tissue loss in a young individual, which is rare. That's not who tears their rotator cuff, right? If I have a 30-year-old who falls surfing and he tears his rotator cuff traumatically and there's no tissue loss, yeah, to me that makes some sense. But most of my patients have this concurrent critical zone damage, which is going to impact how we're going to treat this person. And so we can't throw out the baby with the bath water, and we have to understand that there's still a role for some type of single row repair, and understand that they're not all the same. This isn't 2000 or 2002, and it matters how many sutures you use per anchor and where you put your anchors as you look at the tuberosity. The other thing that's been proven in JBJS is it's really the number of sutures that we pass through the rotator cuff that has real value in getting a successful repair. And, you know, this study from Scott Rodeo disagrees with the assumption on double row. It wasn't until 2016 that the first triple-loaded single row paper was published. And all your systematic reviews were done in 2014, where we really didn't compare apples to apples. And so we've really recreated what we're talking about here, which is what we call the SCOE row. The tension on the rotator cuff matters, and we did a study looking at the difference between leaving the rotator cuff in situ and pulling that tendon laterally. And in a tear that has been torn for quite some time, there's a five-fold increase in pressure required to pull the rotator cuff over the lateral aspect of the tuberosity. And because of that, you're going to have potential issues. But what about bone quality? Who tears their rotator cuff? It's not the 30-year-old, it's the 70-year-old. And when you look at the bone quality on the tuberosity, left versus right, look at the changes. You have this big hollow crevasse here on the right side. I want my anchors here, where you've got the best bone, just off the articular cartilage margin, not out here in this hollow area. If you've ever tried to micro-fracture the tuberosity out there, you know, it just falls in. I mean, the bone's not very good. So what we do, and we've coined as the SCOE row, and I see a few of our former SCOE fellows out there, so thanks for supporting us. We use the strongest anchors and the best bone. We want to maximize our passes per centimeter of tear, and we want to use triple-loaded anchors to do that. Of course, we're all using high-strength suture now, and you've got different suture options that are available. But we want to provide the best healing environment for the rotator cuff, right? We want to fix it where it lies. We don't medialize it unless we have to, but just let it fall right where it lies. We micro-fracture the tuberosity, and most importantly, we avoid over-tensioning the rotator cuff. So this is what it looks like. This is a centimeter and a half tear. We put our anchor in just off the articular cartilage margin. I like to look at the rotator cuff from lateral, lateral decubitus, and I pass my sutures from anterior and posterior, where I'm looking right at it. A lot of people like to use an anti-grade passer, working from posterolaterally, and then passing the sutures. But for me, I can see the pattern best while looking directly from laterally. Once I've passed all my sutures, you know, yes, it's 2024 and I still tie knots. It's a crazy thought. But it works really well. The repair is very strong. And once we've completed our repair and we get all our sutures tied, we then go ahead and micro-fracture the tuberosity. And so I just use a little one-millimeter awl that was from an older implant set that we have. And we create these micro-fracture holes lateral to our repair. And so again, no tension. Rotator cuff just sits where it lies. And then we do what we call the crimson duvet. Dr. Snyder coined this term as his red blanket back in the day. And this is what it gives us, right? So it gives us these mesenchymal precursor cells. It gives us platelets and serum vascular buds that help with healing. So does it work? So this is what happens over time. And so you can see where the rotator cuff was repaired on the left. And that was four weeks post-op. And then we got an MRI at eight weeks post-op. This was actually a radiologist who got on the MRI scanner every month and sent us his images for the first year. And so you can see what happens as you create this neotendon or new footprint that develops on the edge. We've had an opportunity to go back and biopsy the rotator cuff in this area. We sent this slide to Steve Arnosky in Michigan and said, please review this. And this is what he sent back. Polarized light microscopy reveals strong birefringence of tendon tissue. So the tenocytes were aligned. So this does reconstitute. And that's what those precursor cells are likely doing for us. Well, does it work? We published our results in 2021 looking at 100 patients, greater than two centimeter tears. And we got MRIs on every single one. We only had five failures out of 100 patients. And none of those were type two failures. When they fail, they fail laterally. And there were 92% healed. And so that today is still the best result published in the literature on rotator cuff. And if you have a patient with an intact rotator cuff, they have better outcome scores when you look at work scores. So we get excellent healing by MRI, excellent patient satisfaction, and those patients are happy. But well, does it work? Other authors have published on this. There's been two papers out of Korea. This is one that I just found out of Guangzhou, China, using the SCOE-Rho method. So it's been accepted as a specific way to identify this type of repair. And can we improve outcomes if we need to do augmentation? And Dr. Abrams is going to spend a lot of time talking about this. But one thing I'm just going to touch on is the use of dermal graft. And this was a study done by Alan Barber and Joe Burns, one of my partners at SCOE at the time. And what we found is if you have a big tear, you can actually use an onlay augment with dermal allograft and double your healing rate. So the real question is, who needs this, when do you have to do it, and what's your best graft? So for me, augmentation comes from revision repairs that are kind of the massive ones or these at-risk tears that have a chronic component to it and have some significant cutelier changes. And so here's what that looks like. This is an older patient. You can see the tear. We're going to be able to get some closure here using some margin convergence, but our tissue quality is not very good. And I worry about these, quote, margin convergence repair failing and not healing by the time you get to the recovery room even at times. So yeah, I can get the humeral head covered, but again, not a lot of strength. So I want something that has mechanical strength properties as well. So in this case, I'm going to do a dermal graft with an onlay over the top of the rotator cuff. And then we go ahead and attach this. And again, the study has shown level two evidence that this is going to double the healing rate in these big tears. So if I have a repairable large retracted tear, I'm going to fix it and either now use a biceps autograft or this dermal graft. If it's not repairable and I have rotator cuffs, so too, I'll do an off-label use of dermal graft again for the strength. And then if there's no rotator cuff, that's when you're going to hear the things from Dr. Abrams talking about that where we can do an SCR or a lower trap that Basim's going to talk to us about. Well, what about the biceps? The biceps is certainly an important thing to think about and we see it a lot with rotator cuff pathology. And I leave it alone a lot. I'm not French, so I don't feel the need to take it every single case. But if there's any fraying at all, if it looks at me funny, then I'm going to deal with it because I think it can be a pain generator with these big rotator cuff tears. Today, the bigger the tear, the more I'm likely to use it as part of my repair strategy and Dr. Abrams is going to talk about that. So if you have a complex tear, use it as an augment. It works really well. There's lots of things to do. Tenotomy really doesn't exist in my world, right? It's really fast and cheap and easy in the OR, but over 20% of your patients are going to get a Popeye or have continued cramping and they're unhappy when that takes place. And if you have to revise them, then you lose the potential cough savings. But the real issue is this, true informed consent in the office for a biceps tenotomy versus tenodesis is a painful discussion, right? You have to explain to them that they could have deformity and perhaps cramping and all those things that are going to ask. And when you're done talking to them, like, well, can't you prevent that? I'm like, well, yeah, we can do a tenodesis. And so, you know, in LA where I live, nobody wants a Popeye deformity, right? You know, they work out three times a day and they get fillers every month and Popeye deformities are not acceptable. And so it takes you 20 minutes to have this informed consent discussion in the office. And frankly, you know, I'm going to get a negative Google rating because I took too much time. The next patient's going to be unhappy. And now at the end of the day, they all choose tenodesis. So I don't have the conversation at this point anymore. If I do have to do something, I do a tenodesis, right? And for me, the tenodesis has moved from open subpec to arthroscopic suprapec. I think, you know, you don't want to worry about the risks of screw formation with fractures, which can be bad. And so we look for different fixation models. Inlay versus onlay, I think, you know, the results are pretty similar, but the onlays are more problem for me. So I want a tunnel. So we studied this looking at a suprapec versus a subpec. And what we found is the outcomes were similar. And after that, I pretty much switched exclusively to suprapec unless the biceps is ruptured and I have to go find it down the arm. And so we looked at different technique options. This is one of the papers that we published with intraosseous tunnel without any implant. We just basically created a tunnel. So this is what that looks like. I'm looking at it from the lateral portal. We bring the biceps in after we whip stitch it, and then we go ahead and fixate it into the bone by pulling on sutures that we make through a distal hole. It was very slick. It took about 25 minutes, but it was hard to teach and hard for the fellows to learn. And so I said, there's got to be something better. We studied it and it worked really great, very strong. If you use an interference screw, you risk tendon rupture, which is the problem. And so when you think about tenodesis, you have to think about the modes of failure. If you use an interference screw, you can lacerate the tendon and you get a Popeye deformity. If you do an onlay, your sutures can cheese wire through the biceps. And so most people now use two. And if you're using two suture anchors, your costs are pretty high. And if that fails, you get a Popeye. If you do the Abbott, you know, we get a little tendon elongation. You don't get a Popeye, but again, tough to teach. And so with that, we worked on this technique here developing this, you know, space shuttle as it's been called design with a nose that allows us now to go ahead and put this implant at the end. So it's the same basic technique that we were doing before. And then we go ahead and mark the tendon. So I know where the tendon length is so I can restore my length tendon relationship that we want. And I go ahead and basically exteriorize the tendon. I fix it to the implant. And then we go ahead and bring the implant in. You know, you can release some of these vincula and do a tenosynovectomy in this area so you don't have groove pain. I don't think groove pain is a problem with a suprapectinodesis as long as you remove the hypertrophic synovitis that's present. You can then clamp the tendon in lateral decubitus position, measure it and size it, decide what you need, and then go ahead and drill a tunnel. If you're drilling a tunnel in the suprapectral area where you have the struts of the groove, there's no failure. I mean, there's been no reported fractures in this area. So you can make this tunnel and this is what it looks like going in. It's a half sheath design. You basically impact it into position. This takes about 10 to 12 minutes to do from the time we say we're going to do it. It works really well. And, you know, in doing, you know, about 150 of these, Kevin Bonner's done over 300 and this is what we've moved to. So in 2024, the results are equivalent whether you do single or double. The single row repair gives you 92% healing by MRI. We don't get catastrophic type 2 failures. The double row, we can talk about, but it's questionable in terms of the cost. I has dermal allograft and I do a suprapectinodesis when indicated and this new implant may make your lives easier. Thank you very much. All right. Thank you, Mark. So Mark talked about, Curtis, if you could bring me up. So Mark talked about success and I'm going to talk about failure. Unfortunately, not everybody does well. And so this is kind of an element of my practice. These are my disclosures. So rotator cuff repair, as you just heard, what is the major enemy? The enemy is tension too much, technique too little. You don't need six portals to fix a rotator cuff. Tissue quality or loss is something that we have to deal with. There's various techniques going on there, as Mark just mentioned, his approach. And capacity to heal, as we move into the future, of course, this is really where we really want to focus because we can do the work, but can we make it actually be successfully reconstitute to the bone. So what is failure? Well, in my mind, it's someone who's painful, complains of stiffness, weakness. Is a re-tear actually a failure? Well, if a patient had a five centimeter tear and they still have a centimeter or so of non-complete healing and they have no pain and good function, it's hard to call that a failure. Yet, if that patient had an MRI and the MRI was read as a recurrent tear, it would be called a failure in a paper. So it's really, in my mind, a clinical outcome more than it is a MRI outcome. It's really loss of function and unhappiness of the patient six months out that brings it back to the office. Post-op pain factors, how can you eliminate some of this? Well, too much done. So you want to avoid labeled surgery at the initial operation. There's really very little indications to do that. You don't need to take out the AC joint at every operation either. There was a recent paper which looked at rotator cuff repair with and without AC joint resection regardless of the preoperative findings and those where you did not take the AC joint out actually did better. This is the most common problem following rotator cuff repair and subacomeal surgery. What causes that? Bleeding early. So you need to be kind to the soft tissue. I typically do about 90% of my repairs through just two portals. I think it makes a difference. I don't touch the anterior deltoid if I can unless the subscap is involved. And then I'm very careful about making sure there's no bleeding on the way out. Now preoperatively, if they're diabetic or they have adhesive capsulitis, you know you're going to have to deal with that after the fact regardless of how good you are and how much you release. The other thing I've gone to in the last few years, I don't routinely use an abduction pillow. And you're like, well why? Everybody should get an abduction pillow. So what I found were two things. One, we studied postoperative blood clots after rotator cuff repair. And the incidence is about 1 in 500. But if you do a lot of these, you do run into it. And often they see you, you don't see them. And the reason is they often prevent with just pain just proximate to the elbow immediately. And that's where they rest on the pillow. And you're not going to find it unless you do an ultrasound. And we are very vigilant at that. My PA is actually unbelievable at it. Rarely is there swelling in the hand and so on and so forth. And you're treated with putting them on Eliquis for three months. But anyway, so that's one reason. The combination of the block and the pillow worries me. So now I send the pillow home and I say, if you want to use it, use it. And if you don't, that's fine too. Because the other thing that I encourage is some early motion. I tell them they can write and they can type. After a week or two, they can drive as long as they keep their elbow at the side. Because I want some rotation beneath that acromion. And I'll show you why. So post-operatively on an MRI, I never use gadolinium. I hardly ever use gadolinium on a pre-op MRI. Only time I use it is in a possible label tear in a thrower. And even then, that's probably after I've gotten a normal MRI and I can't figure it out. So the problem with using gadolinium is two things. Number one, they don't do T1. So you can't get an idea of the atrophy of the musculature. And number two, you lose information. So you want to know where the collection is. You want to know if there's a bursal collection. You want to know what's going on in the joint. And as soon as you put the gadolinium in there, you lose all that information. You really just want to know the status of the cuff, atrophy of the muscles, and a three-dimensional look at the acromion to see if there was a decompression done. Was it done well? Does it need to be done again? So this is the other thing you see on the MRI. These are the things that we just mentioned. But top right corner here, one of the major failures that I see after rotator cuff repair that brings people back is this. The cuff heals to the acromion. And so how does that happen? Double row repair. So what happens there is someone does a decompression. They prepare the tuberosity. They fix the cuff. The patient goes home. They're in a pillow and they don't move for six weeks. So the cuff heals to bone. So it heals to the acromion. It heals to the tuberosity. And then when you start moving, it's just a question of which interface is stronger. And this is what you end up with. And I'll show you an example of that later too. So what are the treatment options? Well, if you think that their power is not bad and it's a stiffness issue, then I'll do an interarticular cortisone shot under floral or ultrasound. If you do under floral, you can do an arthrogram at the same time and be really curious about the cuff. But again, I probably just would do it in the office under ultrasound. I alter the PT and the work regimen so that I'm really focusing just on motion, just on relieving the stiffness. Because you've got to have motion before you start strengthening. I'm sure some of you have seen that. People are doing pretty well. Then the therapist gets a little aggressive with the strengthening program and they go backwards. So sometimes you can reverse that pretty easily. Okay, surgically. So the goal is to save the deltoids. Because no matter what, the only thing you need in a reverse shoulder replacement is a healthy deltoid. So you want to don't make a bad situation worse. Stay arthroscopically if at all possible. So subacromial revision. So here's a case where, similar to what I just showed you, is that this guy is about a year out and he just never got his motion above 100 degrees. Rotation was good. So that sometimes tells you interarticularly not adhesed subacromial adhesion. So this is what you see. There's nothing to go by here. So what do you do? So you come off the lateral acromion opposite the back of the AC joint and find bone. And bone is home. So once you're on the acromion, you just stay on the acromion. You skeletonize it. Let everything just drop away. And start at the back of the AC joint because you don't want to accidentally start too far forward because you'll release the deltoid. So once you find bone, you can move to the front. You can put a spinal needle in off the front also just to make sure that you know where to stop. So in this case here, this was actually a mini open case here and you can see the sutures on top there. But the cuff, although not beautiful, was intact. So the great thing is these cases, if you don't have to redo the case, they can move the next day. And so it's almost like hitting the reset button. So what about glenohumeral? If they don't get better, this is some of the stuff you'll find. So here's a double row repair. Interestingly, as Mark showed, it's more the lateral aspect of the tuberosity that reconstitutes the tendon. So although a bridge fell into the joint, he still healed his cuff over it. And so what do you do with the biceps? If it's a pain generator, you can tinnitus it, but we never waste it anymore. It's the first thing I look at when patients come in and they've failed and they have a big cuff tear. I just look to see if they have biceps because then I know I can do something for them. So cuff repair options. So I'll accept a partial or a scar repair. In other words, if it's I'm not looking at a hole, if the patient's function is okay, and I'll just do a release. If it's a full thickness tear, that's a type 2 failure there. I'll alter the anchors. I'll repair them. I use the biceps often in various ways to augment my repair because I want to accomplish at least a balanced partial repair. In young individuals, no arthritis, I'll do an SCR. If there's a power issue, if they don't have a teres minor for various reasons, then once they lose their supra and the infra, they have such a lag sign, they can't do anything, and we'll hear about that from Basam. If they're older and they have arthritis, of course, a reverse TSR. So here's the typical revision challenge. This is an orthopedic surgeon who I fixed initially about seven years ago, thought he was pretty cool, and he retore his cuff right there. And so this is what we found. So on his MRI, and Mark talked about patterns, and I love patterns. I've done a lot of work on this, L, reverse L, because most cuffs, especially massive cuffs, have an anterior lateral or a posterior to, sorry, anterior to posterior or posterior to anterior component before they come laterally because you have to split an interval in order to be retracted beyond the glenoid rim. So this guy here, it's basically, on his MRI, he couldn't even see cuff because the entire cuff was retracted posterior immediately. He basically has just a massive L-shaped tear. So once you realize that and you repair this interval split, you're basically reducing the tendon, which thus takes pressure off your lateral insertion to bone. And like Mark, I typically use triple-loaded anchors mid-footprint. Sometimes I'll back them up, especially if I use suture-based with one lateral row anchor, but I don't typically do the typical square double-row technique. And so I use the strongest anchor I can, and I plant it at the point where I try not to maximize the tension. So the real problem, this is the problem that we're all still trying to solve. The massive retracted tear, tissue loss, but not a lot of arthritis. And so, yeah, a lot of people are rushing to do reverses in these, but really, that's their final option. So here, you have to think out of the box and accept the fact you're not gonna be able to get full coverage. So I use the biceps a lot here. You can use it as a free graft and smash it and make it into almost like what Mark just showed as an allograft, but I like to leave it intact if I can. Why? Because it's incredibly strong and it can augment your repair and it can function as a mini-SCR. So I do an in situ biceps tenodesis, and you can see in that top picture there, the biceps runs naturally from posterior to anterior. So right there, if you put an anchor right at the edge of the articular surface and lock it, you prevent anterior superior escape because it's functioning as an SCR. And then it also is parallel to the strongest one centimeter of the supraspinatus. So if you don't have much supraspinatus left, I can then take what's left of it and tie it to the biceps and use it as a jump graft. So that's what I've been doing. And so, basically, it creates a mini-SCR, stabilizes the head, replaces poor tissue, and if I can find anything in the back, I can create a balanced repair. So here's an example here. That's the Terry's Minor. That's no infra, no supra. Not a lot to work and retract it beyond the glenoid rim. That, for those of you who don't recognize it, is an underwater bovie a la Snyder. I still use that quite a bit. So here's the biceps, pretty robust, a little frayed. So here, it's good enough. I can work with that. There's the MRI on the top there. And so I'm gonna put an anchor right behind the biceps, right at the edge of the articular surface, triple loaded. I put one stitch through, one stitch around, and tie them, and then the third stitch, if I think I can get some supra back, I'll save it. Otherwise, I'll capture some of the interval tissue with it. And so here, again, that's basically half the supraspinatus at this point. So I'm tying it to that intact biceps now to utilize it and make it a jump craft. So I've got now an anterior strut and an element of power. And then I was able to find something in the back, so I got a little bit of his infraspinatus intact there. So we would, until about three years ago, two years ago now, this is what we did. And we looked this up, we reported on 40 patients, and we had significant improvements in function and decreased in pain, regardless of the fact we did not cover the head completely. And then a couple of years ago, we moved on to adding something else, which I'll show you here. So here's a good example of a subacromial scar failure. And so here you can see the cuff is basically healed to the acromion. That's the view of the joint, and here we are coming in. And so I'm going to just stay right on the acromion, and I'm gonna release the cuff from that so that I can try to reattach it onto the head. And so here's, after we do that, so we still have some work to do, getting out the old implants and so on. Oh, not the implant, but the suture material. I usually don't take out old anchors unless I need the space. So once we did that, then what we did is we used the biceps here as a, it's underneath there, I tied this over, the front supraspinatus had a little to work with, so I tied that down, I incorporated the biceps, and then, as you can see here, the question is, could we find something posteriorly? And then with a little work, you can almost always find something. And so here, we got the remnant of the infraspinatus, so we brought that up as well, and created a balanced repair. So for the last couple of years, we've been doing that, and then I've been putting in a subacromial device, the balloon, to protect this repair. So this is an off-label use, but what I'm doing is I'm basically making it virtually impossible for that repair to erode against or heal to the acromion. So it's basically a Band-Aid for four months to give it the best chance of healing. So I've never put a balloon in unless I could fix a good, at least 50% of the cough, because I'm not asking it to be a miracle. I think it goes away in four months, so it's not a miracle. But in this scenario, it actually works really well. And a lot of these people have had revisions, and so they're pretty miserable, and the decrease in pain after this has been impressive. We're following this very closely. We've got 50- or 12-month follow-ups, so stay tuned to that. And so occasionally, as Mark showed, I'll use SCRs. This is just a quick example of that. And then revision points just in summary. Avoid treating the MRI report, because the MRI report looks terrible, and now on their portals, patients all get to read them, unfortunately. Focus on what bothers the patient. Is it pain? Is it lack of motion? You can really, it's basically, you can tailor your treatment to that. Remember, tension is the enemy, both at the first case and certainly when you go back in. Soft tissue care is vital. So again, minimize your portals if you can. Preserve the deltoid. Enhancement of biologic healing is key. And mostly, you have to be a cheerleader. Most of these people have been dealing with this for over a year, and they're miserable. And so they come in, they're seven, eight weeks out, and they go, you know, I can only get to here. And you're like, that's unbelievable. I mean, that's the best thing I've ever seen is seven, eight weeks out with a cuff like yours. You gotta remember, you're a 10, not a one as far as rotator cuff repairs. And so you gotta just have them focused. I think these big revisions, it's six months to a year before they plateau. Thank you. I'd like to work on the task of talking about tears that are at risk that we may need to add additional tissue, some form of grafting, and what a personal experience. I think the big thing now is as you work in your ambulatory surgery centers, time, cost, expense is a big issue. It's not only for you. You want to do the best for your patient, but clearly you have people scrutinizing what it would cost to fix this individual, especially when down the hall someone might be speaking about a reverse shoulder replacement, which may actually be a quicker operation and easier on your patient, and that's what you may be going up against. I have a disclosure that a number of companies that I have had a personal interest in, and there's been some reimbursement, I don't really believe it'll matter with this talk. So as you get into these larger talks and you've seen some of the video on this, you realize that there are some real dangers for shoulder and rotator cuff healing. Lateralizing the tendon, adding tension to it, clearly it could be a deterrent. You heard from Mark. The age of the patient, I don't know about your community, but there's a lot of 70-year-old people still trying to play tennis and doing things. There's an 82-year-old guy in the front row who plays every other day. So the truth of the matter is, it's a sport and there are sports out there and people wish to remain active. So you really want to know, what's the duration of the tear? Bob Cofield used to teach us that if someone had an acute change in their activity level, that would be more of an acute extension or an acute tear. And they clearly do better if you get to them before the muscle deterioration. And Basim will certainly echo that statement when he starts getting into his magic. As far as retraction and stiffness, this can often result in an unhappy patient. And yet once you create gap, there is some permanency because this isn't just a tear that retracts. There's often tissue losses that occur with these large tears. So the larger the tear, be aware that this can be a factor. On the other hand, there's these miracle individuals, as in the right where you can see the atrophy in his right scapula. He has really virtually no rotator cuff other than portions of his subscapularis and is able to move quite well. And now it's really a determination not that you're going to make him better or stronger, at least with the operations I will propose. It's a matter of handling pain. And so if your patient comes in with their primary complaint of pain, you have some ability to change that pain with doing these operations you're hearing about. However, strength gains, you better be careful about making any promises that you need to then readjust later on. Multitendent tears are quite different than singletendent tears. And be aware that's when you will see sometimes that fixed superior migration you see on a standing or upright x-ray. Do not base that on your MRI findings. So when we get to tissue and tissue grafting, it's really tears that you feel either you cannot close or you can close but you feel that there's going to be a high risk, which as you know the literature supports, in some cases over 50% disruption or partial healing. So you have the biceps. You heard about these briefly in the other talks. Biceps is probably the least expensive and most available tendon. It can be tenotomized when it's symptomatic. But when it's not as symptomatic, you may wish to use it as part of your solution rather than looking for allografts or xenograft tissue. And this is a physician in my community. He's in his 70s. He had a large to massive tear, multitendent tear. And this is what we can expect. When we close this tear as best we can and then augment, be careful about your MRIs and making major decisions on your MRIs. I think they're helpful. And actually the fat infiltration began with CT studies even before MRI studies. They do mean something. A weak muscle is not going to turn into a strong muscle. But what all of us are speaking about up here is what's happening to our tendons because that's all we're really dealing with when we get an arthroscopic view of the shoulder. What we really should be thinking about is what's happening to the muscle immediately because that's really, the tendon is just the attachment point. I really don't believe we recreate tenocytes. We probably recreate some fibrotic tissue that closes the tear and allows the muscle to function in improved fashion. This is an easier way for me to deal with this. And Steve Burkhardt has helped me with this. But this is, I think what happens on the posterior superior tear or upper border subscap when in combination with other tendons, you get superior migration. And that's fixed, not dynamic, but fixed because most of them probably do have some dynamic component if you ask them to elevate their arm in abduction. But this is on an upright x-ray and when the humeral head is articulating with the acromion, you have to have a multi-tendon tear. This is no longer a single-tendon tear. And so what you would like to achieve is stabilizing the humeral head against the deltoid action. And that's done by fixing the anterior cable, the posterior cable, the anterior cable being localized very close to where the biceps is traversing your shoulder. And the posterior is into the infraspinatus. And these are the fixture points that if we can achieve, even if we cannot completely close the crescent area in between them, we can often come out with a more satisfied shoulder. That anterior cable, when it's disrupted, they get the internal rotation weakness. The belly press sign is the easiest for my rather robust people in Princeton. They don't have to put their hand behind their back like they're getting arrested. In that other case, you could also see sometimes deficiencies in active forward elevation. You'd like to see good passive motion. But they have a shrug to create the ability to lift their arm. And the posterior cable also is important when they start getting that weakness. When they get a lag sign, I think you need to listen to the next speaker about what they may do to achieve an improvement. Fixing rotator cuff tears with chronic lag signs and external rotation, which means I hold the arm, I let go and it comes back to its resting position. That's not a prognosis you want to say you're going to achieve with a cuffed repair. So poor selections is when you get the acromial articulation. We call it acetabulization. In the event of arthritis, there are degrees. The more mild ones, you may consider doing some rotator cuff work if they're young and active and physically sometimes employed steel workers. You may look the other way on some early arthritis. But as the arthritis gets more serious, be careful about doing these type of operations. Make sure they have good passive range of motion. Under anesthesia, examine your shoulder. And if they do have some adhesions, manipulate them right now. You may as well fix a shoulder that has good full passive motion. If you have restricted passive motion, you can't expect the physical therapist to achieve your goals. Understand capsular releases. In many cases, we go inferiorly in capsulotomy. And we're looking at the back of the muscle as we cut the capsule. Beware of unusual biceps positioning. When we're done actually fixing the supraspinatus, we'll leave the scope in the lateral portal and release the lateral margin of the coracoid, which brings the supraspinatus. Lou Bigliani used to talk about that open slide where he's put his scissor down going along the direction of the biceps to the coracoid. And you can do this nicely with a bovie. Here comes the bicep story. For me, it's the least expensive. It actually doesn't take much to do. I have a little bit of a different procedure than what you heard. I think that you can look at the biceps. You could realize that there is some pain generation. This is a nice, safe tear. And I'll release the biceps from the superior ligaments. I'll close my tear. And then I'll retrieve the biceps anteriorly because I put a stitch in it before I released it. And I'll tie it to that anterior anchor, which is near the articular surface. And then I'll draw the biceps in and sew it into whatever I need to. In this case, I'm sewing it across to the infraspinatus. So this is really a dynamic biceps in the sense that the biceps still works distally. It's not attached to the superior labrum, so I don't have to worry about restriction and range of motion, which can occur if you're doing these operations in the lateral decubitus position because the arm is sitting in internal rotation. In the beach chair, you tend to neutralize your position and have less concern. But be aware, if you're going to leave it attached to the superior labrum, the biceps, you can actually create a check ring of passive loss of external rotation. And so I think that this works particularly well as an onlay graft and covering the footprint. It adds to collagen. It also bridges the front cable to the back cable. And so I do feel that incorporations of this may only be partial biologically, but it's the collagen and it doesn't take long. Here's just a larger tear where I utilize this. You can see the articular view. I still like to do some decompressions. People have mixed popularity on this, but again, in the lateral decubitus, I think your view is better and your access to your tendon is better. And we're trying to recreate the shape of the tear. This is sort of a mixture of this particular one between a reverse L shape. There's the anchor placement, the first one. And I like the, you may want to use the combined mattress simple suture. This way it acts like a ripstop effect, the mattress, and then the lateral drill holes that you heard about earlier with Mark's talk. Here we're grasping our biceps. We put our stitch in before we release it so we don't have that embarrassment of trying to retrieve it after it possibly may migrate down the arm. Again, with the patient's arm in full extension, you do have some tension on the biceps. And in this particular case, again, we fix it to our anchor in the front, which is the same anchor that did the initial cuff repair. And then we bring it over the top into the infraspinatus. Bovine is another tissue that has been popularized. This is a tissue that can be an onlay type of graft for the partial or full thickness repairs. So the idea of an onlay bovine, or this company, is that it is relatively negative in terms of initial strength, but does quickly incorporate into the tendons. So it provides thickness to the repair. And so one of the problems with rotated cuff repairs is that we can end up with a problem with a repair that is intact, but thin and not effective in depressing the humeral head or stabilizing it during this. This is a particular case. I don't know what you would all do. This is a patient who has multiple surgeries, workman's comp, and he ends up with a thin, atrophic tendon. And so your options are to take it down and try to see what else you can do, or to incorporate and try to thicken what's already there. And so that's the articular view. That's the MRI showing multiple areas of deficiency. And in this particular case, we did an onlay bovine just to thicken the tissue and create a better attachment point for that muscle to the tuberosity. The video I'm about to show you in the bottom, if it does work from here, will be a person who gets a second view because they had adhesions following this. And somewhere about eight months postoperatively, again workman's comp, we had an opportunity at least getting a second look at what this might look like. So this may or may not work. Oh, let's go back and see if we can do that. I'm not sure what I should be pointing at, actually. Oh, here we go. So this is a second view of this. This is about nine months following the initial bovine onlay. This was an articular tear. You can see, I wouldn't promise you tenocytes because I don't think we create tenocytes, but I do think that it's fibrotic tissue or scar tissue that tends to fill in the defects. And again, I'm looking for attachment of my muscle medially to my tuberosity laterally. And I think that you could see some of the previous either sutures or anchors from this particular case. And you realize you don't have perfect tissue, but you have a more stable endpoint. And I think you could count on somewhere about two millimeters of thickening at the end of the day. Des Bocar from Australia had a lot to do and has had some second measurements with MRIs, and that's what he achieved. And in a case where you have an intertendinous tear, that you have to decide, am I going to take this whole thing down and then do something to try to repair it? Or could I just place an onlay graft and incorporate some biological activity with the onlay healing and the intertendinous filling in on MRI, at least, then I think we may accomplish our goals without starting the healing process all over again in some of these revision cases. These could get more exciting. You get a 55-year-old plumber and actually a magician on the side. I got to do his other side recently and put his tendon together and then placed one of these grafts on top to avoid the adhesions that can occur to the acromion, which was what I walked into when I started this case. This is him afterwards. And I got to meet him now. He continues to be a magician, less so a plumber, and he's in his upper 60s. And I did his other side about 15 years after the first operation. There are now some grafts that are bovine that have some additional strength to them. This will at least let you move them more quickly. We're trying to get people to leave the six weeks within the sling and the six months of restricted activities to something less. This will be a patient who, again, was a revision case. This is his tear. Basically, he's a CEO. He's 56 years old. He's active. He plays golf. He does physical things. This graft goes in as generally an onlay. So you try to do what you can with the tendons, maybe leave the original sutures in place. And here I am just trying to give the lateral margin of the graft some additional fixation as an onlay indication for this bovine tissue. You couldn't do this a month ago? I could do maybe a little less a month ago but over my head no I'll show you when I go over my head. Okay show me what you can do gently and carefully don't cause your pain. All right that one this is what you want to see. This I couldn't do before the operation. And how long ago was the operation? Well your operation was a month ago but the one before that was 18 months. And you couldn't do it between the two operations? No way. Okay excellent. So that patient was told he should stop doing that he's only about six weeks out so his surgeon can sleep at night. There's superior capsular grafts you know back in this meeting probably five years ago a large part of this meeting might be devoted to superior capsular grafts using allografts to fill in the defects. You're finding now that there's some other alternatives and then you're hearing some of this this morning and you're going to continue to hear more after my talk a little bit on what you may do. It's often the supraspinatus that's a part of the tear that you can't do much with. The infraspinatus tear often has some degree of correctability if you can bring it back to bone. It seems to have more mobility. So here we can bring our graft in. I think that again we've been questioned in the United States on the thickness of our grafts. The Mahada's work clearly showed that six to eight millimeters was better than what we were using which at the time was probably two or three millimeters in terms of thickness and now we're trying to do things where we get at least a four millimeter graft inside. Again as an augmentation device meaning do some tendon repair and then put the graft on top may be the best approach. Rick Ryu has actually combined a biceps tenodesis with a graft to try to achieve the eight millimeters of thickness. So think of different ways to recreate the subacromial space which if you think about it is really the balloon but may have some positives and negatives. This will at least stick around. So in conclusion I'd like you to think about the larger tears as tears that don't. You may leave the room and feel like you've done a great job. The question will be will it go on to heal. The statistics would show that there's many times deficiencies in our overall healing even though we often have happy patients. Maybe they're happy because they don't want you to put them through another operation. Maybe they really are happy. So we all want to have some type of complete closure when we're done. And there's no question that the grafts can aid in the closure. Remember what you're trying to do in that room is achieve the muscle to bone activity of the rotator cuff and the tendon is the bridge between the two. So think of different ways that you can achieve success in closing holes and allowing that muscle to function normally. When you don't have a normal muscle function this will be your introduction to your next speaker. So I think about the cable a lot. I like that anterior portion to help stabilize the initial elevation. Tissue grafting I think is something you're going to hear about and unfortunately has its expenses involved. I think that you should think about tissue repair as best you can and then replacement or augmentation with grafts whether you use the biceps or some of these other techniques. I wish you luck. Thanks for all. Thank you, Jeff. All right, let's keep this rolling here. So our next speaker, Bassam El-Hassan, he's the Chief of Shoulder Surgery at the Mass General. He just voted best dressed orthopedic surgeon in the world. I cannot argue with that. And so he's going to tell us what he does with these very difficult cases. Well, thank you so much for having me. As you notice, like how many treatment you have right now. I'm going to add to it. I don't know if there's right or wrong about this one, but I'm going to talk about augmentation. So I really like to look at the shoulder as one unit. Like we're looking at the rotator cuff in a very, very small window. But in reality, the shoulder girdle is incredible. And this is here what's interesting. We look at the deltoid as the king. In reality, it is very important. But in my opinion, the rotator cuff are the important players. But why? Why the rotator cuff muscles are very important? Because though they are very small, they are very powerful. And I'll show you how. This patient, this is everyone see this one. Massive rotator cuff tear. I'm not talking about the zebras where you have massive tear, they can move. The majority of them, they cannot move. Especially with this one, I call it anterior escape because they have anterior superior rotator cuff deficiency, and they have massive rotator cuff tear. Now, let's see what happen if the rotator cuff are perfect, but you have completely paralyzed deltoid. That's one, that's two, that's three, that's four. I have a lot of these. Every single one of these has complete deltoid paralysis on one side. And if you do your standard rotator cuff exam, you're not going to find it because there are very specific exam. Myself and Bertelli from Brazil, we came up with them to determine the deltoid because if you do your normal jobs, everything else will be normal. But the deltoid is gone. But this is how much powerful the rotator cuff are. So this is why when, as Jeff mentioned, I call it a fluffy, if someone like fluffy, or if the deltoid, if the rotator cuff are fat, I don't think you can repair fat. So what can we do to reconstruct? I understand that you can try to restore the cable, but if you can restore the dynamic with the muscle that's gone, I think this will be optimal. But this is a very nice piece of meat. If the rotator cuff are nicely healthy, it's different than it's fat. So you cannot repair fat. It will be scar tissue, but it's not fat. It's not dynamic. So no muscle, no life. I think JT Tokay should always talk about it this way. No life. So, but how to reconstruct the rotator cuff using muscles? Like how can we build it up? Anything you need to do of the tendon transfer option should be based on a very good understanding of the anatomy and the biomechanics of the shoulder. Because this is how we'll be able to transfer safely any muscle. And if you have a massive rotator cuff tear, assuming you have no tissues you can repair, or you can, the classic is latissimus, that many of you know about. Teres major is another option. And the lower trapezius is another option that I'm going to talk about today. Now this is what's very interesting. This is what we tend to forget. You take the scapula. It's a very thin bone. You can put your finger in it almost. And all the rotator cuff hugs this muscle. And when we look out of all of this, we're looking into that tear in that tendon to try to repair. While the anatomy, we sometimes tend to forget about the anatomy and how it is. So when you look at the rotator cuff, you have all of them hugging the scapula sitting on the chest. Every single rotator cuff is a posterior structure. So when we talk about anterior and posterior rotator cuff tear, you should make sure what's the reference. Because if the reference is a chest, every rotator cuff is posterior. There's no anterior. But we think about this way. This way we say, so pectus anterior, we do transfer anterior to the subscap. And posterior latissimus, we do it this way. It's wrong. Because I showed you right now, the scapula hugging everything is the boat. And all the rotator cuff are posterior. And one more concept. This is not the purpose for this, but you think about it. We compare external to internal rotation. But what is different between the two? When you talk about external rotation here or here, they're comparable. But what's the difference really between the two is this motion. You cannot compare external to this. Because this is ER, IR, ER, IR. But this is different. So they're completely different animals when we compare the two. And when we look now to see how we're going to reconstruct the rotator cuff, if this is one boat, and I'm looking at another boat next to it that looks exactly like it, the trapezius matches exactly that anatomy. And this is why we like the trapezius transfer. Again, you look at it, you look at the scapula on the chest, one bone, all muscles the same direction. And you look at the line of pull, the lower trap matches completely. And in fact, this week, I did lower trap to subscap. I'm not going to talk about it right now. But you say, wait a second, how is subscap is anterior? No, it is a posterior structure. So any transfer to be ideal for the rotator cuff, it should become from the side of the rotator cuff. Otherwise, it's not optimal. We can argue about it later about, for me, why pec does not work. But this is why all the transfer should be coming from posterior. So when you look at the houses, we look at the boat, you can see they look like twins. The line of pull is exactly the same. And a lot of people ask me about like, wait, wait, but you're detaching the scapula. If you know what I do, I have the highest respect of the scapula. So if I know something is going to affect the scapula, I will not do it. So this transfer will not affect the mechanics. If anything, it will improve the mechanics of the scapula. So anatomically, kinematically, biomechanically is the best transfer because of everything I mentioned. And there are many, many papers and more papers are coming up right now. I'm glad people are gaining interest in it. Now, because it matches the right rotator cuff biomechanics, it works for brachial plexus. So now here, we're not talking about massive rotator cuff tear. We're talking about no muscle paralysis. And this is how we started. This is my first lower trapezius 2007. Patient has no muscle, no brachial plexus injuries. It means every tendon is intact, but there's no muscles. So this is the first one. Big incision, big Achilles tendon allograft. I excise the medial spine of the scapula, transfer it to him. This guy, I like him very much because when he came to me, he likes to drink. And he's right-handed. And he hates the fact that every time he wants to drink, he pushes his hand because he does not like to drink with the left hand. So I told him, can you do anything? And this is where at that time in 2007, when we came up with it and studied the anatomy, I told him, well, this is something we just studied right now. We have the paper. Do it. We did it for him. And this is him. He came after one year. Then I did for him a flip the pect for the deltoid. And this is him at 10 years. Well, yeah. So, and this is him at 15 years. So this is again, no rotator cuff tear. This is paralysis with pedicle. So this is a true functionality. And this is Achilles tendon after 15 years or more. And we've done more than 700 cases for brachial plexus. So if it worked for brachial plexus, why would not work for rotator cuff tear? Brachial plexus is much, much more challenging, of course. So, but the patient selection is very important. So even this patient, he came to me from an out of state, a massive rotator cuff tear. He's a physician, young, active, massive tear, advanced atrophy, no ER. And this is what Jeff talked about. No muscle, no life. You want to repair it, he has pain, it's going to get better. You have no muscle, it's not, where are you going to get your external rotation from? Like you don't have it. It's what's very interesting also when you think about the concept of external rotation. Deltoid, little bit, the two main muscle, infraterrest minor. Everything else work on internal rotation. Even gravity, when you put your hand, it puts you down. Everything, back, lat, terrest major, everything. But you have two muscles that give you external rotation. So this is why when you don't have this muscle, it's not easy to restore just by repairing rotator cuff, this fat. Now, how do we do it? We started with this. Then for rotator cuff tear, we did the transacromial approach with an Achilles tendon. Then like anything, we progress from open to arthroscopic assisted. And now we call it SALT, scope-assisted lower trapezius transfer. In fact, on the concept, it's called SALT. Even the OR nurses, they know about it. They tell me, they do this like, so do you have SALT today? Tell them, yes, we have SALT today. So SALT. And how it's done, this is very quick because of the sake of time. And if anyone have any questions, I have video technique. I'm happy to share it with you. Medial incision, you get the lower trapezius. We'll open the infraspinatus fascia. The Achilles tendon, we love Achilles tendon allograft, even though there are other options. We go in. The biceps tendon, again, from the very beginning for me, if it doesn't cause symptom, I'm not touching it. Now I do like to add it, but it does not affect what I'm going to do. Then deep to the deltoid on top of the infra, not through the deltoid, because I've seen many cases through the deltoid. You should not put it through the deltoid, deep into the subacromial space. And then this is your Achilles tendon. And usually the fixation, now I use like four anchors technique. If you have any rotator cuff, you can try to repair. The only reason I repair them only for soft tissue, vascularization or something, not because I'm relying on them at all. So you get the Achilles tendon to the front, and you have the first anterior medial ankle and lateral ankle, then from medial to lateral. And then you put the shoulder in abduction external rotation during the passing of the allograft into the lower trapezius, because this will shorten the distance between the head and the trapezius and give you better tension. There are many techniques of pulver tafting, and then you put the arm in abduction external rotation. Now again, big opening, thrust acromial. And now this is what we do, like my PA will be preparing the graft. He's here, like the fellow will be after a couple of times, they know how to harvest, it's very easy. And then I will be inside the shoulder or vice versa. So I have a triple team. And if we don't do like rotator cuff repair, it takes like 35-40 minutes, it's not too long. And immobilization, this is tricky part, because I really like them. Again, because when you don't have any power, anything push against it, so I really like them to be immobilized. We can start passive motion and abduction external rotation, but I don't like them to stretch in internal rotation. I love aqua therapy, and then we do progressive strengthening. So it's around six months of recovery, but I tell the patient, even if they felt great at six months, they're going to feel even better at one year. Now the outcome, this is the patient, like they're not always this way. I want to show you how it is an active transfer. Latissimus, there are so many things talked about the latissimus, that it is passive transfer. This one in this patient, he likes it. He said, there's nothing back on my shoulder. And this is essentially his lower trap. And you can see you actively, you don't even need imaging for it. You can see it actively during rotation, during flexion, during abduction. It is an active transfer. And in fact, Bob Tajian right now, he's doing study and showing EMG in face work of the lower trap. And so that nobody will ask me, when you transfer the trap to the humerus, it's pulling the scapula in, so you're not losing the effect of the lower trap. So why no additional SCR? They always tell me, yeah, you should do SCR, because I don't know why the concept of you should close the joint and whatever, but if you remember, we're doing tendon transfer. We're trying to reconstruct. We're changing the anatomy to restore the anatomy. But in this patient, a few patients, I did not do it for them, the biceps. I went back in, because after three years, they have some pain. I went in. I did not touch whatsoever the proximal part. I just did lower trap. And this is how they looked. They're completely sealed. This is the scar tissue maybe you're talking about. The body is amazing. And I showed you, this is like that window, we're looking into this whole scapula. There are a lot of things can happen here. I think you need to balance it. If you don't balance it, you're not going to have the migration and the humerus sticking on the, or the rotator cuff sticking on the acromion. So if you balance the shoulder, the body is going to seal it. It's not like, let's add tissues, let's add, like no, why? Well, this is working in my hand. It's working in their hand. Everyone is like have their technique, but this is what I can show. And this is a patient, this vascularized graft, and it's completely sealed without any reconstruction. So, and I'm happy to see like it is spreading worldwide. I have zero financial interest. I have no instrument, no graft, nothing under my name, except the technique. So there is nothing for me in it except the technique. So, but now from all around the world, I don't show my result anymore. I like to show like what other people have been doing. And I have many, many other, but like, this is from all over. This is from the Emirates, the first one, and a Murphy in United States, Mexico, Barcelona, France, Chile. And it's, it's, it's, it's working. And this is not two, three, five years. Now my longest pull-up is like close to 17 years. And now we have been teaching, teaching about it. And I just came back from South Korea. And in South Korea, there's a big shift with the use also of the lower trapezius. And honestly, they're technically very skilled as well. And this is Changbi, one of my friends from South Korea, just showing like patient with completely R-lag and what happened after the lower trapezius transfer. But the graft option, this was very interesting because also a month ago, I was in India and they don't have Achilles. So they use the peroneus longus, which I was like, it's, it was perfect. I loved it. So we have hamstring, peroneus longus, Achilles quadriceps allograft, Achilles tendon allograft as well, facial autograft. And this one, I know we're not going to do it. There's certain people in Brazil, they do the middle third Achilles tendon autograft. I will never do it here. I'll end up in prison, but like, you know, so like at least show it. And there are a lot, a lot of study right now coming up about all of these techniques with very good outcome. So for me, yes, the lower trapezius is the way to go. If you want to learn about it more this year in November, here in Boston, we have our tendon transfer course and scapula course is going to be here in Boston, November 14, 16. Everyone is welcome. Thank you very much. And Dr. Paul Sethi is going to join us. Paul is great on the podium. He and I have had some things that O said over the years. And what I've learned is if Paul's at the podium, you sit as far as you can down that table. Also, we have a microphone here. So I would encourage questions from the audience as well. Irene, would you mind passing this around if someone needs to ask a question? This is my PA, makes my life easy. Thank you. All right. Thank you. We're going to go fast because you guys talk too much. You made a lot of really good points, mostly a third of which I believe hard cuff cases. Yeah, right. Like I'm going to poke a hole in the bone to grow a tendon. We're going to really have to talk about that one a lot. So let's we're going to go fast through things. I'm not going to get too far into the history. This is about technique. Normal x-rays, subscaps intact. Pretty large cuff tear. Young guy. We're all joint preservers. This is Anna. So if we say reverse, we'll probably get kicked out of the room. So we're not going to go down that pathway at all. And Jeff, you talked a lot about this now. And we talked about joint preservation using different graphs. So the first one is going to be discussion of biceps. I'm going to sort of start and stop. I call it anterior cable reconstruction. I don't call it biceps SCR because I'm really doing what you guys talked about. I'm restoring the anterior cable and preventing escape and trying to balance the balance the shoulder. So there's some points here that I think we can get into. Look here, bad biceps. Jeff, would you still do a bicep procedure, a biceps type of anterior cable with a bad biceps like that? No, if the biceps is that involved, I would not. I'd probably have to. Again, you can send patients ahead of time. And when you see something that you know, you may have trouble, whether you know about the biceps or not, have a graft as a possible option. Yeah. So I totally disagree with you. I think the biceps is better than any tissue whatsoever. It's better than any dermis. It's better than any bovine. It's better than, and it's cheaper, right? So here I am, I'm going to repair the cuff down into place. I didn't get into the SCOE fellowship. We can talk about that. I had to train on the other side of LA where we did double row anatomy. So here I am taking this lousy biceps. And the way I do it is I pull the biceps into the area where I need to repair. So I'm going to go ahead now and make Mark Edelman sick and do a double row repair on this bad tissue. I'm going to spend all that money and look for anatomy. You can see as I pull on this tissue, it's deficient. It's hard. I do pass retrograde, Mark. I did learn some things from you appropriately. And once I slowly pass the retrograde, I want you guys to comment quickly, because I'm going to rip through these cases. Anything anyone's going to do differently in terms of, are you going to do a single row repair? Alan, you? On this one, I'd fix the interval. It's a reverse L pair. So I'd fix the interval and then I could probably do that with two anchors. I think that's a really important point, restoring the anatomy. Basim, I'm going to wait till the end for you to talk about these things. I mean, you can say anything you want, but there's no transfer happening here. Now, the next question, and Jeff, you brought this up. You're like, look, if you leave the supraglenoid tubercle intact in the beach chair, it works really well. But in the lateral, it causes stiffness. And I think I have three lateral people here, right? I think that's crazy. I mean, it doesn't do that. So you're saying he's the ex-president, you can't say he's wrong. Well, his point is where, you know, one thing that I didn't make a point on is that when I tinnitus the biceps in situ, I drop the arm down to 15 degrees of abduction. He's correct. If you do it out in the 70 degree of abduction, you tinnitus in situ, it's gonna get stuck coming down. But if you bring it down, and actually, the arm's usually externally rotated, not internally rotated, because of the thumb up in the abduction sling. So, we just haven't seen that. And the other way you have to look at it is these are disasters. I mean, these are not, these are basically think out of the box and use anything you can type of situation. So, you know, but that's a good point. Bring the arm down 15 degrees so you don't over constrain. So, again, I think it's very relevant. I actually have some different videos where I show after you tinnitus it in place, as you bring the arm up in abduction, it actually gets looser, it doesn't get tighter. This is not a throwing athlete that you're worried about getting the fast, past 30 degrees of rotation so they can find their slot. The biceps tendon, whether you're looking at Larry Field, Paolo Linus, or the European studies, it's by adding that tendon is gonna reduce your retear rate from close to 25% in the average study to close to 5%. So, the question I have for you guys is why don't you do it more often? Well, you know, I think if the biceps is there and you have any significant tearing, there's no reason not to. Steve Snyder, for the last five years of his career, never released the biceps from the superior tubercle. On any rotator cuff that he did. And, you know, it's been published, didn't have stiffness, it worked really well. So, yes. Yeah, I mean, it's the question is why not to use this free tendon? We're putting in these commercial grafts that cost $3,000 as a potential augment or a potential add-on. So, I guess what I, the way I look at it is I'm always thinking of the next time, even though I prefer not to ever come back. But if I can get a good repair with native tissue, then I probably would not do the bicep. Because I don't know if I need to come back. And I just did a guy yesterday, or Monday, with Traveling Fellows, who I did his repair eight years ago. And he was fine, he fell off something hung by his arm two months ago. Ruptured everything. But he had beautiful biceps there, so I did exactly what I showed. I mean, I think what you're seeing is a huge C change. If I was on this panel four years ago, biceps tendonitis, always get it out, French, French, kill it all, right? And now I'm hearing everyone say, well, hold on a second. First of all, it's not the pain generator in everybody. You don't need to just get rid of it. And in fact, if there was no code, I wonder how often, or if it got bundled in, I wondered how often we'd be doing it. And Alan, for you to say that maybe we should save it for later, I think that's very, very insightful. And it could be important. This guy, we have volume? No, maybe. I really need volume. Badly, crying. Good, bring it out. Push it towards the sky. Hold it like this. Just let me adjust you a little bit. Push into my hand. Good. How's the shoulder feel? Feels great. If you could rate it between zero to 100, what's your honest rating? It's 95, it's great. Got it. And why are you here today? Because left shoulder also got torn. Got it. Yeah, right, I didn't operate on that guy, actually. That was normal. He was just coming in for a normal visit. I'm gonna skip this case. We're gonna go to the third case, just because it'll be fun. Mark, that's what a double row repair looks like, just in case you wanted to see, right? That's what I call pre-op. To make you feel better. That's what it looked like afterwards. There's a type two tear, so you can be vindicated. Exactly, there it is. I made you happy. That's the only one that's ever happened. But let's get to the last case. Here we go. Normal x-ray, 51-year-old woman. She's got a subscap tear. No significant atrophy of her subscapularis. So I go in and I do a, I can see her biceps. In this case, the biceps is a problem. Subluxing into the rotator cuff, it's like a center lesion. And I go ahead and do a straightforward subscap repair. And she's doing great. I don't know, probably seven weeks post-op. She's like, you know, I slipped and fell. I was walking my dog. Okay, how often do you get an MRI after, first of all, how often does that happen to you, that someone had an event in their perioperative rotator cuff repair? Weekly. I mean, a lot, right? Almost always. Almost always. So how often do you guys choose to get an MRI when, you know, at that point in time? Rare. Anyone in the audience gonna get an MRI like when they have an acute, no, no chance, because you know it's gonna look terrible. It's gonna look retorn. And you're praying to God that this isn't gonna be an issue. So I prayed to God. In this case, I did a subpectinodesis. I like to get the biceps out of the way when I'm repairing the subscap. And, you know, it's pretty low down. Anyway, a year later, I got to get the FNMRI. And now here we go. Hopefully it'll play for me. She's got a big subscap tear. So Jeff, what am I doing? So let me go back a second if I can on the MRI. So I try to tell patients right off the bat that their healing processes could very well be a year. This is before their first operation. So if I'm going to do an MRI, it's probably gonna be around month seven or eight, only because I'll have a more reliable picture as Paul just alluded to. Early pictures are very hard to interpret and probably will be inadequate to help you with the decision. If you get something around eight months, though, and you have something relatively small to deal with. Yeah, no, I got three minutes left in this case. We're gonna get there. Oh, 830, no, 815 is on my schedule. But the point would be that you would still have an opportunity to deal with the problem. All right, so what are you gonna do? You probably didn't hear it because you're talking. As it turns out, I'm the moderator. You know what, you're done. Mark, president or not. So I won't repeat it. President or not, you can't talk anymore. Take him, turn his mic off. All right, Mark. There's a little bit of muscle. So again, if there's muscle, there's hope. You may be able to get something. You could do an extension graft on this. If not, then you're looking at a tendon transfer. So tell me about, is that an arthroscopic procedure? Tell me about an extension graft. Yeah, so arthroscopically, I still think I can see the subscap really well looking at it. And so if I can mobilize it, I feel safer mobilizing it arthroscopically than open just because I can see where the nerve is. And then I can just add a dermal graft to get length. You could add an Achilles graft to get length, and then I would repair it that way. So this is gonna be an intercalary graft from end of tendon or an onlay graft? Intercalary. Alan, what about you? First I'd call Basam, see if he was busy. I actually really wanna hear what he does with the subscapularis. But I mean, similar to Mark, although I'd probably lean to doing it open, actually. You'd lean to doing it open. So are you gonna augment this? Unfortunately, in this case, I didn't listen to Jeff, and I wasted her biceps early on. It's a T and D topic. How are you gonna augment this? And let's discuss for a minute, emphasis augmentation versus sort of capsular or tendon augmentation. How do you think about that? You know, it all depends on how close you can get that. Those tendons don't move very well. So, you know, as Mark just said, you're probably gonna need length. And then, you know, that's your graft. I mean, if you can get it all the way back, then you can use anything that you like to augment. Dermal allograft, you know, whatever's gonna increase the tendon bone interface and give it some strength. So it all comes down to whether you can get back to the lesser tuberosity or not. So I think that it depends. You're gonna put a graft in this most likely. Grafts and revision surgeries are not uncommon. I think if you could get it to the lesser, just even the articular surface medial edge, you can medialize this a little bit, but then it's an onlay graft. If you can't get it there, then it is an intercalary graft. Got it. Bassem, I don't know about what you transfer yet. I wanna save that for a couple of minutes, but how are you thinking about this? Would you try something arthroscopically? Jeff, was that arthroscopic for you? Yeah. All right. Yeah, yeah, absolutely. And like, because augmentation's gonna be with anterior, all arthroscopic latissimus transfer. All arthroscopic. Yes. Okay, so look, she's gonna tell us what she's feeling, right? Spoiler alert, this woman had surgery. Tell me what's going on with your shoulder. Well, I can't put my hand on my hip. There's just, some motions just don't work like they used to. Got it. Hand on hip, what else can't you do? Well, stirring at some point, it's just awkward. The higher plane I'm in, the more difficulty I have doing something. If my desk was here versus here, I can't, you know, I can't type the same way because I can't do things where my elbow has to come out. See, I thought this was relevant because a lot of the time, you don't pick up some of the nuances, some of the subtlety of the exam. But if you listen to her history really carefully, she's telling you what she can't do. Men will often tell you they can't get their belt up when you're talking about subscapularis. Her exam's pretty impressive. Good. Hold it just like this, not through the elbow. Push your hand into my hand. Palm into my palm. Let's try it on this side. Maybe you can be better at it there. Palm into my palm. I still could hit you, you know. So I like to examine, is there any special trick? I like to examine the subscap up here as well as down here. Alan, any special subscap exam trick for you? No, I do. I just, I find the belly press very, very informative. You know, even a slight lag, you know, a portion of it. I don't really get into it too much. You know, that's what I do. I think the only time the belly press will be a trouble is if they have an internal rotation contracture. So they always have that elbow next to their side look, even if they don't have, even if they have a good subscap. Good. Tone of external rotation here, right? All right, Bassem, so I made you happy. Oh yeah. I didn't mean to show this slide. I just kind of screwed up. No, but just quickly, this is exactly what I was talking about. Notice, external rotation, this, this. Internal rotation, my hand is down, up, this way. You don't talk about that external rotation. This is how complex it is. It has so many, like, things in it. Anyway. So to the panel, who would do a pec transfer for this? You'd all do lats? To the audience, pec transfer is the standard answer for this. There's the most literature for, not post-arthroplasty, but for an irreparable subscap tear with very good results. So I'm just curious. Would anyone in the audience do a pec transfer? Wow. You really changed the mainstream, because I think that would have been a mainstream answer. So here's what I did. This is only about a minute long, I think. Here I am coming down delta pectoral interval. That's the latissimus right there, staying very far lateral on the latissimus. You know, it's very easy to release up, and by staying lateral, you can avoid getting the tears along with it. If you can keep it ribbon or band-like. Now, I did something else here. I took a dermal graft, and I put a dermal graft across the anterior capsule, or anterior cable. So that dermal graft goes onto the glenoid. I'm preparing now the lesser tuberosity, and I'm gonna make a sandwich here. Spaghetti sandwich. There's the latissimus coming up. I used a total of three anchors, so I placed one anchor mid-tuberosity to sort of get mattress sutures through both the anterior capsule, as well as the latissimus, and then I used two additional anchors more superiorly. I tried to get it into the groove, the anchors into the bicipital groove, but in this case, I really couldn't get as much excursion, and I wanted to keep her in about 15, 20 degrees. So, you know, just wrapping it up, I guess, Bassem, let's give you the insight on how do you think we did this? Would you have done differently? Why would you do the anterior capsule? This is beautiful. Very sexy. I love it. But right now, except if I have an implant, all of this, I do them arthroscopic, either completely arthroscopic without any opening, or I make a small opening because the excursion you're talking about, if you have an anterior superior with some dynamic escape, you cannot get to the supraspinatus. It comes only to the lesser tuberosity. So, I go through like three centimeter incision, get the tendon from here, augmented Achilles tendon, I pass it arthroscopically, and put it the way you put it, but more proximally. I mean, this is a plug to go to his latissimus transfer course to learn how to do this arthroscopically. I would like to. No, this is wonderful. Do you have the outcome of this patient? She's about six months out, very happy, you know, still working a little bit, and I don't think the strength is fully normalized, but her SSV is substantially improved. So, the next session starts at 8.30, the commute is really short. So, if you want us, we can keep going, or if any of you have questions, we can go on till, it's 8.20, we can go on five more minutes, but if anybody has to go, fine, otherwise we can finish up at 8.25. Yeah, sure, I'll do one more case in here, and I kind of went backwards on it, but this is a woman who I did this nice double row repair on, I think putting an anterior strut, you see the suture on the bottom left, so I think fixing the anterior and the posterior cable, Jeff, you alluded to this, if you can get a good cable reconstruction, I think even if you have partial tears, you do okay, but she's now, again, eight months out, and still in pain, so I do get the MRI scan. She's still constrained, right? You know, her Shentons are more accurate, her Meloni's line's intact, she doesn't have superior migration, and I think the X-ray holds a lot of value in rotator cuff surgery. You know, as you talked about, acetabularization, or even subtle disruption in the balance of the shoulder. But she's re-torn, right? She's got a big re-tear, she's got tendon or meat on the bones still, she doesn't have a lot of edema around the anchor, so I'm not really worried about an infection, I know we talk about that all the time. Alan, how often is it that you have an infection as a cause of failed rotator cuff surgery? One in 500. Yeah, pretty uncommon, right? So, you know, I don't go looking for that unless there's some other sign. Jeff, is there any specific sign or signal that you say, oh gosh, this is more trouble, this doesn't seem like an honest mechanical or biological failure? Yeah, I think you go through the normal blood work, you do an aspiration, if there's some fluid, as you can see on your MRI, and if everything is checking out satisfactorily with two weeks on your cultures, you're okay to keep going and assume it's mechanical. So now that Mark's not here, we can really pick on him a lot and his scowy ideas, but this is a type two re-tear, so that tendon healed to the bone, I can see my sutures actually covered or synovialized, that felt really good, my repair is awesome, but I've got a medial tear, right? So now what, guys, who wants to take it? Bassem, what do you got for me? Well, me, myself, if the tendon is repairable, I will, but definitely I will augment it with a lower trap, just for the augmentation. So you'll re-repair, there's reasonable muscle belly, but you're gonna put a lower trapezius in addition to that? Augmentation, yes. Got it. Yeah. Jeff? I'm gonna use the long head of the biceps if it's still there. Yeah, so I should've saved it again. Look, that's a good point. Maybe this biceps is gonna be relevant. See, listening is a key to these things. So I would repair the tendon, I would augment it with the biceps. If I didn't have the biceps, then I would use another, a different, like a bovine onlay. So Alan- But the one with strength. Bovine, some structural. Alan, do you take out all that lateral tendon, or how do you actually, how do you re-repair this? So, no, I would find the edge of the articular surface and I'd create a landing zone for about a centimeter, centimeter and a half off of it. And I'd take out any prominent suture material, I wouldn't touch the anchors. And then I would alter whatever anchor you used the first time I'd alter. It was suture-based. I could use suture-based again if she has good bone. If she doesn't have good bone, then I'd use either titanium or plastic, whatever you want to give it more augmentation. If you had solid anchors in there, then that's when I started using suture-based, you can come right down next to the old anchor and it's like reloading it. So, can I just quickly ask a question? Why do you, he had a beautiful repair. The tendon was good at that time. Why do you think it failed? Why now you want to do something different because you did a great job the first time? Why did it fail? Tension. Tension. Oh man, you really, Gennel is not here. You just did a single row revision on her. You're saying you over-tensioned it. Now you're gonna say Crimson Duvet makes tendon now too. Paul, these pictures may be just a little bit off and I can't see it as a type two. Type two is almost a muscle tendon tear. This really looks mostly lateral disruption, at least by your MRI in the top corner. So, in that one, Ionati failure in situ, that the tendon elongated a little bit. Yeah, you know, maybe that's an insightful comment. Roland Mayer, if you're gonna graft this, what graft are you gonna put on there? Well, it depends on whether you can get everything back to, if you can get it covered, then you can just do it. I mean, you helped train me. You put everything together again. So, let's say you did it. So, if I put it together, then I have to do something, I'll find a conductive graft, a bovine conductive graft. A bovine conductive, yeah. Fabio in Brazil, what graft are you putting on there? Well, we don't have grafts in Brazil, so we don't have their biceps, we killed the grafts. I killed, huh? Mm-hmm. So, we have blue grafts. Huge mistake, huge. So, see, we have a tendon transfer. So, you might add a tendon transfer because you're at other graft. Would you take the other biceps to control out all biceps? No, nobody? One taker in there, anyone? Come on. It's early, people are still drinking, all right. So, look, we have all these different graft choices, and I think all of them offer something different to the table, and really, you know, I tried to get into this idea of emphasis fixation. No one bid on it. In this case, you know, where does it fail? Like, Jeff, does it fail at integration into the bone, or does it fail? I mean, I know we can say suture-tendon interface, like that's a biomechanical weakness, but where does it biologically fail? I think in this particular case, it was the tendon-bone interface where you had your failure. Tendon-bone, all right. So, here's a case that's slightly different. Yeah, don't feel bad, Bell, and hopefully I'll play. AVT, there we go, good. So, arthroscopically, this is a slightly different case. She's demonstrating graft. I think it's important to demonstrate that subscap's intact, right? The subscap has to be intact. Here, once again, suture's failing to heal down to the bone, but you do have some healing out laterally. This person had persistence of pain. So, I get up top and I can see the suture material. I'm always removing. Whatever form of material's in there, I'm gonna remove. But, Alan, you're right. I don't wanna take the anchors out too aggressively and have a Swiss cheese type of glen where I'd have no point of fixation. So, you made a very relevant point. Here, the tendons split, but you're gonna see something that I think is interesting, right? Because we think that all anchor material's so benign, I go to look at where the old anchor is, right? I'm like, hmm, this was an all suture-based anchor. I'm cleaning it out a little bit, and as I'm cleaning it, I'm like, gosh, this doesn't look that great. You reach it. You get that glob of crap, right? Yeah. That is just, like, what are we putting into the human body? Now, I need to fix that. I need to get fixation at that point, and I can stack anchors. I can do all sorts of funny tricks, right? But, I'm already thinking I wanna limit. You need healthy bone. Jeff, you said it in your talk, and Mark said it too. You need healthy bone, right? So, I'm teeing myself up here, and I'm gonna drop an anchor in here, but I'm gonna put in some calcium phosphate cement or bone grafts. I think you have to have healthy tuberosity for it to heal, so that's what I did here, and then I dropped an anchor in over that. You could've used a DBM just the same, but I think to leave it as a big cystic reaction, synovial fluid will drop in there, and then I'll go ahead and do a side-to-side repair as we get through this and sort of get some configuration, and towards the end of it, I'll drop a graft in, but that'll be sort of the fun discussion point. I think dropping grafts in is expensive and tricky and adds time to the case, but how do you choose what graft you're gonna use, Alan? Do you use all the grafts, and do you use one graft just routinely? I use skin if I'm gonna do something, allograft. Dermis, yeah. Jeff, what graft do you choose? Sometimes the choice is made for me based on the institution they allow. Now they kind of go through the budget on everything, but the truth is I've moved a little bit away from allografts, meaning pomacutane, acellulodermal, because of its stretchability. You put it on there, and then you start stretching it, and it really doesn't resemble the original shape after a while. So I prefer the more synthetic combined bovine grafts now. I think they incorporate well, and they maintain their shape till they incorporate. And the data supports both of these, so I have to wonder where the truth is. Bassem, if you're gonna put a graft in, where are you gonna put your graft in? Just lateral to repair, because this one, if you're able to repair it, most of the time it cause more media, as you said, tension-free, then I just drape it next to it. And what type of graft, and what's the rationale? In U.S., I can extend an overseas hamstring or perineus longus. So you're gonna use a hamstring or a perineus longus? Overseas, yeah. Got it. So here, I used a dermal graft. You know, there's lots of ways you can prepare it. I think we're gonna finish right now. I tend to put the dermal graft in, yeah. Don't feel stuck staying. If anyone wants to watch the video, we run it out. I know we're running late, so. Well, thank you all for coming. That was awesome. Appreciate it. Thank you. Thank you, John. Appreciate it. That was fun. Good job, man. Good talk. Thank you. I like it. Thank you very much. Thank you. I love this. That was fun. I know. It's a good idea. You made my day. You made my day. We might need a little bit more time, thanks. What? If you have any way you want me to put our talk together, something that we can probably do.

Orthopedic surgeons

Rotator cuff tears

Repair techniques

Revision surgeries

Anatomy

Muscle penation angle

Tear patterns

Surgical approaches

Biceps tendon reinforcement

Bovine grafts

Chronic tears

Tissue loss