Hi, my name is Justin Griffin. I'm here to talk to you today about an exciting topic in shoulder surgery, which is new treatments for massive irreparable rotator cuff tears as a part of our Anna Fellows course 2024. We're six weeks out now, so I'm excited to share some different concepts with you, but I'll start with this, which is a great experience. Fellowship is amazing. These are some of my friends and mentors to this day. An amazing year to enhance your future practice and life. Well, this is a problem we see every day. We can see patients with massive irreparable tears. They can be very retracted, very difficult to deal with, and it's hard to select the right patient for a particular operation. Here on the right, you can see a tear that really has no tendon. There's really not anything left to repair. Well, the questions that we have to ask is who really needs an arthroscopic option versus a reverse shoulder? How do we fix the graft and where do we fix it, and who's really the optimal person for this surgery? There's some technical tips that I'd love to share with you, and we'll go through some of the outcomes for a lot of these different techniques. We know that for massive tears of the rotator cuff, there's a number of limited surgical treatment options. I say limited because none of them are perfect. We can consider a partial repair. We can certainly consider other options, and some of our more active patients who would like to avoid a reverse shoulder replacement. Superior capsule reconstruction has been popularized as well as a newer option of a tuberoplasty. There's also balloons that can be used in the shoulder, reverse shoulder replacements, and tendon transfers. All of these have their own challenges, and it's about selecting the right patient for surgery. Well, managing these irreparable tears is very important, and making that decision, there's some good algorithms you can find such as this article that was published in JAAOS demonstrating who we can consider for these salvage options. One of the questions that will plague you early in your practice is who is the right patient for not replacing their shoulder? These are harder conversations in the office. Sometimes it can take a while to talk somebody out of surgery and to talk them into something that you think is a good idea. If we can keep the humoral head lower, the suggestion is the patients may have retraining of their shoulder, have less pain, and improved function. If we go back to the beginning, Dr. Himi Hadda performed the superior capsule reconstruction to restore the stability of the shoulder, and what he was really trying to do with the tensor fasciae latae eight millimeter graft, we've not been able to truly reproduce in our US series. The consensus is there's no great options for some of these younger patients, and we don't really know exactly what is perfect in them. The reason that we can consider things like tendon transfers is also apparent because we're trying to avoid a replacement. If you look at the series of very good surgeons such as Dr. Mazzocca, we find that there's a high failure rate and also high complication rate. Dr. Bassamel Hassan has popularized the lower trapezius transfer, which is a great operation for the right patient. I personally use this in my practice for significant extramotation lag or extramotation loss for massive tears, and in patients it has been purported to potentially reverse pseudoparalysis, and I think we're all getting better at this and learning more about this technique as well. The reverse shoulder replacement, I do a high volume of shoulder arthroplasty in my practice, but there's complications with this. There's been some series that even talk about a 39 percent complication rate. Certainly that's much higher than would be expected, but it's not a perfect surgery and there are some problems that can occur. You can see this x-ray here demonstrating a pretty bad situation for that patient with multiple revision surgeries. Our newer reverses have potentially more optimal options for lateralization, and maybe we can decrease our complications over time. I think we're getting better and better, though it's not a perfect operation and certainly not for everybody. I think we need to think more out of the box. This is an opportunity area in the realm of shoulder surgery where we're trying to keep that tuberosity centered, avoid pain in those patients that don't run a replacement. If we go back to the beginning, again, we've talked about Mihata. When he performed these SCRs with a tensor fascial autograft, he got 83 percent healing, and so this is something that we've been trying to replicate. If we look at our own data in the U.S., this is Steve Burkhart's study showing a 12 percent conversion to reverse. 75 percent success, but not 100 percent, not 95 percent like we see in a lot of areas of orthopedics. Well, it's not for this patient. A true pseudoparalytic patient with a massive tear that can't be reversed with pain relief is not the patient for an SCR or any tuberosity graft or tuberoplasty procedure or a balloon because I don't believe that this can really reverse true pseudoparalysis. This patient needs a reverse shoulder replacement perhaps. When we assess our patients, we look at their pre-op motion. We see if the rotator cuff is truly repairable. I always consent these patients for repair, possible dermal graft procedure, because we want to have the freedom to use whatever we need to without waking that patient up and saying, sorry, I wish I could have done something more for you, but we'll bring you back later. We want to consent them for everything for that shoulder, but we're committing them to the arthroscopic option, not a possible reverse at that operation. The subacromial balloons have been used more recently. When Atwal looked at this, he showed that it decreased the superior humeral head migration and perhaps restored more normal glenohumeral joint position, and when compared to an SCR, there was no differences. Does the healing in a shoulder from an SCR perspective equal better results? Perhaps not. If we look at these series, you can see them outlined in that table. A high rate of glenoid situs failure. In some series, up to 50% failure rates. Less improvement though. If the tuberosity is covered, the patients seem to do fine. This became a thought area for myself and my partner when we originally thought about how we can cover that tuberosity for these patients. Well, let's look at another study. There's no correlation in this study, Dr. Burkhart series with some skilled surgeons. There was no graft correlation with tendon healing and clinical outcomes. Even if the graft was intact on the tuberosity, the patient did well. Well, Dr. Mirzaian talked about the, quote, tuberoplasty effect, which is if it healed on the tuberosity and that tuberosity was covered, the patients did well. If the tuberosity was bare, that's where they had more problems. You can see on the samurai, there's a graft on that tuberosity and this patient had a failed SCR on the glenoid side, but was doing well. So this led myself and my partner to consider this concept of a tuberoplasty. The graft healing does not predict success. We know in this study published by Dr. Gillespie, there's 62% failing rate and the healing did not affect the outcomes. If we look at this, we don't know if actually that humeral head depression is the real reason why it works. If you look at the overall U.S. experience with SCR, there's overall positive outcomes in difficult patients with a lot of skilled surgeons publishing some heterogeneity of whether a repair was done in addition to an SCR, but a lot of these patients are doing well clinically overall. The balloon is now an option for our patients. We have to consider who this is the right option for, but there is some concern maybe about migration of the balloon, potentially some failures. So I think more to come here. I think it's certainly something to consider, something to continue to evaluate in the future. SCR with a dermal graft is also an option, placing this underneath the acromion as popularized by Dr. Ravenscroft and even Dr. Tokish to try to get really max thickness on both sides to prevent that contact. So where are we now? Well, we did this study, a survey study looking at how many patients are still getting SCRs. We've seen a decrease over time. We've seen an increase in bioinductive grafts and certain populations of surgeons seem to want to do more bioinductive grafts than others. When we pass these grafts for an SCR, for instance, suture management is everything. That is the key, going slow, really getting this graft in very safely without a lot of suture management and tangle, but this is a hard surgery. This is something that takes some practice and something that can be challenging and can result in a lot of time in the OR. And so we move this graft into the joint very carefully. Here's a video demonstrating that graft being moved into the joint. We push it in while pulling on the knotless glenoid anchors to get that large graft in. We can then fix it. We can fix it to the actual rotator cuff and to get that complete capsular continuity and great incorporation of the graft. Well, what about a cuff plus an SCR? Well, this is something that I think is a great option. I think it's important to move these patients early. Some of them can get quite stiff, but may add to potentially stability and strength for these patients. This is what it looks like at the end. You've incorporated your SCR both posteriorly to infraspinatus and potentially even anteriorly to try to really get complete continuity. What about the biologic tuberoplasty? Well, this was a concept that we thought might be reasonable to do for our patients because what we were seeing was the same thing that was published is maybe this tuberosity graft, if we just put it right on the tuberosity and not necessarily fix it to the glenoid, perhaps the patients would do well, and that's what we've seen in our patients. We use a thicker graft here, even a four to five millimeter graft, and we can fix it on the tuberosity, maybe a little bit more expedited recovery as well as quicker in the OR and less costly for our patients. Preoperatively, we look at these patients. I wouldn't do it in a patient like this that has true pseudoparalysis. We want to do it in somebody that has reasonable range of motion that can elevate above 90. They have an intact subscapularis with no significant arthritis. If you want to read a little bit more about this, we've published our technical note on this looking in the arthroscopy techniques at these massive tears, and this is what made us originally think of doing this is placing this graft, which has now been termed a tuberoplasty, onto the greater tuberosity. The preliminary outcomes, Dr. Mirzaian published his series of 10 patients demonstrating intact healing on MRI as well as good outcomes, and we're collecting our data as well. This is what it looks like. You can see this bare tuberosity, no repairable rotator cuff for this patient, really no hope of a repair. Let's go for a case. This is a 56-year-old active male with right shoulder pain, persistent pain for several years, failed and attempted repair at an outside hospital, very active in CrossFit, does not want a replacement under any circumstances. Well, this is what his MRI looks like. You can see that retracted tendon, some atrophy and contraction. It's something that we'd want to consent him for possible repair if we can get it over because we weren't in the shoulder before, but potentially considering something salvaged, something non-replacement. This is what it looks like in the operating room. I'm shuttling in the graft. His tendon wasn't repairable. We're pushing it in while pulling with the knotless anchors just to the tuberosity. Again, the surgery can be done if you do it a few times in 10 to 15 minutes once the graft is sized and ready to go. Oftentimes, now there's an available graft that can just be fixed right to the shoulder and doesn't need to be cut down and is very expedited. This is the position. I do this in the beach chair position, make my portals. This is not this patient, but I'll just demonstrate to you that this is a repairable tear. It just has a different configuration, different patient, reverse L-shaped tear. We can get this over and repair this very nicely. Take some time to consider the tear pattern. First step is to prepare the tuberosity. I medialize that and then I measure for the graft. Now, some of these are, if you measure it, some of them right out of the opening are very nice. We can fix this. You can measure in a couple different ways. This is where the anchors go medially and laterally. You can then fix this to the rotator cuff. I use a knotless technique where we grab this suture. You can then repair it even through the tendon in the back to incorporate it with the graft. We can pass that through and get a rotator cuff repair as well. Then we can pull in the graft once we bring those sutures over. This is how the graft prep looks. We can pass a linked suture laterally. We can then bring the graft over to the patient's side. We can then bring the graft up and we can shuttle it in. Once that graft is prepared, we can use the sutures that are already in the patient and pass them through medially to bring the tendon over. These are just some linked sutures that you can use if you want to make it a little bit easier. This is the graft going in. You can see that graft being passed into the passport cannula. It's then going to enter the shoulder very easily and be shuttled on top of the tuberosity. You can see it pulled down with a four-corner technique. Originally, I was bringing tapes over the top. Now, I'm just fixing it in the four corners to get that nice prevention of the bone-to-bone articulation underneath the acromion. Here's the anchor going in. You can see the lateral anchor going in both anteriorly and posteriorly to get our full four-corner repair. Lots of different techniques out there to explore, but the whole concept is covering that tuberosity as a pain relief. I don't promise my patients strength improvement, but many of them do actually improve their strength. This is Paul Sethi's picture demonstrating a repair over the top of a tuberoplasty concept to get potentially even better strength. There's lots of options, lots of things that you can use to repair this, push the graft in while tensioning laterally. This is our technique. I published this with my partner, Dr. Bonner, who's been instrumental in this technique and the development of it with me and some other surgeons that are doing this, Tal David and Dr. Mirzaian around the country. Postoperatively, we move them much more quickly. At six weeks, I let them out of their sling. We don't really hold their range of motion. This is my patient at six weeks, the same patient that I demonstrated in this case, 56-year-old guy, and he did very well. This is him at a year out from surgery. He's now two years out from surgery demonstrating preservation of that acromiohumeral distance. Our patient numbers are growing. These tend to be more active patients that want to avoid a reverse replacement. This is the concept. We're pulling in this graft. It's technically a little bit easier. It doesn't absorb and go away. It's less risky not to manage anything on the glenoid side and so provides a good option for the right patient. Outcomes, there's been lots of patients that have MRIs after surgery. This is Dr. Mirzaian's MRIs demonstrating healing of that graft to the tuberosity. As far as our technique, you can find this. This is our outcomes early. We're still collecting these as well as MRIs demonstrating complete pain relief with decreased prepotence and night pain. Again, don't promise strength, but a lot of these patients do seem to improve. Selection is everything. We want to set the expectations right regarding strength. We want to cover that tuberosity and do the decompression last to prevent a lot of swelling and avoiding tendon transfers in certain patients, but those are great options as well as a reverse for patients with pseudo-paralysis of the shoulder. It's just a closing thought. I love this quote. It's supposed to be hard. If it wasn't hard, everyone would do it. The heart is what makes you great. These can be hard patients to deal with in operations. Building your practice can take longer, but really indulge yourself in evaluating the patients, getting to know them, staying conservative when you can. Surgery is a last resort, and that will make you busy over time. Pay attention to your travel, your family, and your hobbies. Thank you for your attention. Good luck in the rest of your fellowships and in your early practice. I am always available as a resource if I can ever help in the future. Thank you.

rotator cuff tears

shoulder surgery

patient selection

surgical options

tuberoplasty