All right, good evening. Thank you guys for sticking it out today. It's been quite a day of education and, you know, I don't think three years ago this talk or this ICL ever would have happened or had anybody in the room because, you know, up until recently, the biceps never mattered, right? We just cut the biceps and if we were all French here, we'd certainly have an empty room. We'd be at the pub already having cocktails because, you know, if you just did tenotomy all day long, we don't have any of these things. But yet, I think we've really changed our mindset. And I know for me personally, the first thing I look at when I see a rotator cuff tear now is is the biceps intact or not because it really changes how I have a conversation with the patient. Do I have to talk to him about an expensive graft or not? Do I have the biceps and we have all these great options and our goal today is to kind of give you a thought process on how we use the biceps today and, you know, we have thought leaders that are going to help enlighten us. We've got people who've described these techniques. So with that, we're going to jump right in. Dr. Anakwansi is unable to be here from Duke, but we have his talk video recorded and so we'll get him involved as well. So with that, we're going to have our first talk from our new second vice president, Kevin Bonner. Thanks, Mark. So we're going to start from the beginning and just go over tenotomy versus tenodesis and does it matter where? I know a lot of you, how many in the audience still do tenotomies routinely versus tenotomy? Hands. Okay. All right. Good. So as you see, a lot of people, you know, still do tenotomy certainly. My disclosures, Mark and I have actually developed a biceps tenodesis device that's currently available. So if I show any pictures, that is my disclosure. So basically, tenotomy versus tenodesis and we've all sort, you know, various variations on this talk. Obviously, tenotomy is easy, cheap, quick. You avoid tenodesis complications and there are complications. Most do do well, however, we worry about the cosmesis and Popeye sign and cramping versus tenodesis. Let's face it. It is more common. There's a lower risk of Popeye. But the risk of Popeye is still in the 6 to 27% range with doing a tenodesis. I will say that if you do a tenodesis, and people don't talk about this, if you do a tenotomy and cut their biceps, you know, the rate of getting a Popeye sign is in the range of 15 to 44% depending on what article you read. If you do a tenodesis and it fails, it's 100% you get a Popeye. So just to think about that. And then obviously less cramping. But let's face it. For me in the office, I think a lot of people do great with tenodesis, but how much of us have heard, what do you mean you want to cut my biceps? And honestly, for me, if I could talk about doing a tenotomy, that sometimes could be a 15-minute conversation in the office versus tenodesis, of course you can fix it. So let's face it, for a lot of us, you know, that's part of the rationale. So we've done some studies on this. So going way back, we looked at patient satisfaction after biceps tenotomy. And actually, most of the patients were actually still quite satisfied. But if you really look at spasm and cramping, about 20% of them still had significant spasm and cramping. And a lot of times, it wasn't once in a while, it was more than five times a week. And interestingly, age had no effect on that. So then if you look at a lot of meta-analysis and things that have been done, tenotomy results. Patients again can do very well, 2012, 95% satisfied or very satisfied, Walsh, 86%. And then another study in 2012 with almost 700 patients showed 77% had good and excellent outcomes. So let's face it, a lot of patients who get tenotomies can do very well. So let's look at the Popeye rates following tenotomy. So there's a wide variation. It's in the 10% to 25% range, but there's a big variation. I put that there was one study 70%, but honestly, most of them are in the 20% to 45% range. This was 43%. This is a systematic review. And again, remember, if you do a tenodesis and it fails, you'll have it 100% of the time. And just going over that and some of the actual data. So failures of an inlay versus onlay. And when I say inlay, that means in this study, it was a screw that was going into a tunnel. Their failure rate was 21%. And then with the onlay group, it was 6%. So we're not going to get into right now the tenodesis, but the bottom line is that we still have a ways to go to improve upon that. This is another study with a great group. Looking at, again, inlay, they had a 20, and a very good surgeon, Pat Denardin's group, very, very good. Inlay, 27% post-Popeye deformities. Onlay was virtually 10%. So I know a lot of people have gone to onlay, but in our opinion, still 1 in 10, quite honestly, is still too high. Is Larry here yet? Oh, yeah. Oh, there he is. So this is one of my patients who came in to see me. There's lots of ways to do tenodesis, too. This is a guy who went down to see Larry, and you can see one of Larry's great results with his tenodesis. But the point is that there's a lot of different ways to do tenodesis. Larry has a great technique called the triple fix that he's done. So there's a lot of different ways to do tenodesis. And then looking comparatively, the bottom line is that even though this is non-inferior, a lot of patients tend to have less Popeye deformity, certainly. They tend to have less, not just cosmetic issues, but less spasm, less cramping when you look at it. And so this was another study that we published a few years ago looking at patient satisfaction, and we looked at tenotomy versus tenodesis. And the bottom line is that the patients without tenotomy had significantly more spasms and cramping, although interestingly, their perceived Popeye, meaning asking the patient, do you think you have a Popeye? And we explained what it was. It was no difference, believe it or not. So they're both viable treatments, but again, the trend is, in general, less cramping, less spasm. And to be very frank with you is that it's a much quicker conversation in the office telling somebody you're going to fix their biceps compared to cut their biceps. And various different meta-analysis, basically some of them showing no differences, and it's difficult to draw conclusions. So they're both viable options. There's no question. There's not a right or wrong answer. But I think we're all seeing that a lot of our patients, especially in the United States, tend to more desire tenodesis versus tenotomy. Now tenodesis location, is there evidence for one? Basically, supra-PEC versus sub-PEC, and obviously the sub-PEC is open. And just to summarize, and these are all recent reviews that have been done over the last few years, and the bottom line is that there is no significant difference between arthroscopic supra-PEC or open supra-PEC versus open sub-PEC. Now the mantra was, if we go back 10 years ago, all these people were going from doing arthroscopic to sub-PEC because, oh, all this groove pain, and we all came to meetings like this to see one picture of a biceps that was inflamed lower. But if you actually look at the studies that have been published in the data, there's actually no significant difference in bicipital groove pain between doing it supra-PEC or sub-PEC, if you actually look at the data. In fact, for every study showing slightly increase in groove pain with a supra-PEC, I can actually show you a study that had more groove pain after a sub-PEC. So if you look at the data, the answer is there's no significant difference despite what we all talked about 10 years ago. There's various different ways to do it. There's a technique with Alan Curtis. I showed you Larry's technique earlier. This is one little point regarding that. Of all the different meta-analysis, this one study did feel that if you do a soft tissue repair where you put stitches in proximally, they did have a slightly higher incidence of groove pain just in that group. And so this was not included. This was just published. This is a level one study done by Brian Forsyth, and he was the lead author. He's the one who orchestrated the study, but you can see the rush group. No difference in arthroscopic supra-PEC versus open sub-PEC tenodesis. The one thing I would caution you, however, is that the difference in complications, and granted, a lot of surgeons who are very, very good, quote, unquote, never get a complication with doing sub-PEC, but if you look at the ABOS data, this was published, basically, you can see open sub-PEC had a 1.5% chance of a complication. Basically, one in 60 patients had a significant complication, and these were not minimal complications. Some of these can be bad complications, so just something to keep in mind. So tenotomy versus tenodesis, both are reasonable. Treatment selection is really driven by your personal experience. Obviously, a lot of the younger surgeons were you trained, but I think clearly, clearly, a lot of us have gone more towards doing a tenodesis. Most patients feel they would prefer a tenodesis, but remember, tenodesis can fail, and if a tenodesis fails, they pretty much always get a Popeye sign, and quite frankly, realistically in the office, when you're seeing all these patients during the day, it's a much quicker pre-op discussion stating you're going to fix their biceps versus just cut or release their biceps. So there's lots of different studies looking at location and technique. The bottom line is that a lot of this is based on surgeon preference and their comfort level, but there's no difference in bicipital groove pain if you actually look at the data right now, despite what we all said. And we all feel that there's actually room for improvement for tenodesis, because there are still significant failures. Thank you. Awesome. We have some seats up front, if you guys want to move up, you can certainly do that. Next we're going to hear from Dr. Ana Kwanze from Duke, professor of shoulder surgery. Unfortunately, he wasn't able to be here, but he did put together his talk. This is the one that has the audio, so let's cue that up, and hopefully it plays. associated with this. Some examples include whether it's super-packed versus sub-pack, whether it's inlay versus onlay, different types of techniques, and then implant choice, which is going to be the focus of our conversations today. So in terms of the fixation options and strategies, I've broken it down into four main options, interference screws, part body anchors, buttons, which can be unicortical or bicortical, and finally, all suture anchors. I think in general, based on biomechanical and clinical data, I think it's important to try to find a balance between fixation strength and stiffness versus tissue viability. For example, you will note that interference screws may be associated with high times zero stiffness, but are also associated with risk of soft tissue failure. Before we dive a little deeper into fixation options and tools, what about the idea of soft tissue implant-free tenodesis, i.e., are implants even worth it? This was a study from 2011, AJSM, looking at soft tissue implant-free tenodesis versus traditional bony fixation with an anchor. They had clinically equivalent outcomes. However, when you look particularly at the bicep score, you can see that the soft tissue tenodesis option did not perform as well with a higher incidence of cosmetic deformities as compared to the bony fixation option. These cosmetic issues we know are likely associated with bicep failure or rupture following tenodesis. Moving on to the focus of our topic, this is a nice systematic review, looking at different fixation options and their biomechanical outcomes. To begin with, noting no difference between super-PEC or sub-PEC, but when you distill it further and look at predictors of ultimate failure load, noting that the interference screws were the most predictive of ultimate failure load, followed by the number of sutures being used. However, when you go beyond ultimate failure load and you actually look at predictors of type II failures, specifically when the tendon ruptures as opposed to the implant failing, we noted that the suture anchors and addition of more than one suture were predictive of preventing these type II failures and at risk for type II failures was interference screw fixation and likely for some of the reasons that I will discuss going forward. This is a nice randomized controlled trial. Many of the studies looking at fixation types are biomechanical studies for obvious reasons to be able to control the experiments. This was a nice clinical study, 33 patients who had interference screws, 34 patients who had suture anchors and noted that seven of 33 patients with the interference screws were noted to have failure based on MRI ultrasound evaluation of all patients in this study. And again, noted no difference clinically, but certainly a significant difference in terms of efficacy of biceps tenodesis. Why might we have some problems with interference screw fixation? It might be a combination of high stiffness. There's not a lot of tendon elongation or compliance with interference screws. This is in addition to the shortening of the tendon as it's dunked into the tunnel, which leads to a length tension imbalance and also the angle of insertion. And finally, the fact that most commonly single suture is used. I think all these together might explain tendon failure post interference screws. This is a study looking at suture only fixation, but unlike the soft tissue only fixation, this is intraosseous, a complex stitch configuration, a finger traffic configuration, and overall just a complex and more robust suture only technique. More robust, but also potentially more complicated to perform. But in terms of biomechanical data, this all suture technique performed better than screws alone. This is in terms of failure load, failure stiffness, failure stress, failure strain, and failure modulus. Just as important and something to note is the change in cyclical loading times zero to 500. On the screw subgroup, there was a significant difference in terms of the decrease in stiffness, decrease in modulus and hysteresis. And I think this should be noted as we do this in patients clinically that over time, the performance of the screws do tend to give away very dramatically. What about buttons versus screws? In general, this was as shown in this study, no significant difference. But when you think about buttons, this study did a nice job of elucidating the fact that biportical buttons do place the axillary nerve at significant risk. For this reason, I don't recommend using biportical buttons. They found a mean distance of two millimeters from the button to the axillary nerve. And in this case, I think the risk might outweigh the benefit. What about all suture anchors? This is a busy slide. This is a nice biomechanical study performed at Rush. And in summary, they noted that there was no difference between all suture anchors and traditional conventional anchors, but the suture anchors compared to screws were noted to have higher tissue elasticity, less displacement, and higher stiffness of failure. Importantly of note, they noted almost half the specimens with screw fixation had early failure before full loading, so catastrophic failure. This slide talks about all suture versus buttons. Of note and importantly in this study, there were similar suture configurations using the Krakow lock stitch configuration. And they noted no difference in displacement or in force required to fail between both groups. Now, that's in comparison to another study looking at all suture anchors versus buttons. But in compared to the last study in this study, the button group received a whip stitch as shown in the left here, and the all suture anchor received a Krakow lock stitch configuration. And in this study compared to the last study, the Krakow lock stitch configuration and in this study compared to the last study, the all suture anchor was noted to perform better with less displacement, and also less than significant improvement in terms of ultimate load and stiffness. So I think this study highlights the fact that suture configuration does matter, and different implants may allow you to perform more sophisticated suture configurations that might improve your clinical outcomes. So in conclusion, we see good outcomes with different implants. Suture counts and configuration are very important and may be as important implants being used. Screws may have a relatively high failure risk. Bicortical buttons are risky to the axillary nerve, I don't recommend usage. All suture anchors and general conventional suture anchors do have a history of good performance. All suture anchors may have some general advantages to conventional anchors, but that's beyond the scope of this presentation. And finally, and perhaps most importantly, I think it's important to consider what works best in your hands. Ease of use, your approach, if you're doing it open versus all arthroscopic, your field of visualization may change and certain suture configurations may be more difficult. So I think it's important to think of everything in totality when you want to decide what implant to use. Thank you. All right, can you pull up a Gettleman now, thanks. So now we're gonna kind of shift gears. That was kind of your basic overview on what you knew about before you got here. And what we're really gonna talk about now is how we've changed and how we use the biceps today. So we're gonna go through a series of different uses of the biceps in dealing with massive rotator cuff and how we manage it. My disclosures are at the website and on the app. So here's our case. So we have a 66 year old swimmer that I see this patient all day long, every day, right? She's got vague shoulder pain for years. She has a tennis accident six months prior to her presentation, and now her pain has gotten worse. It's now severe and weak. No response to anti-inflammatory medication or physical therapy. She's no longer able to swim and she has significant night pain. She has 120 degrees of active forward elevation and abduction, so she's pseudoparetic, not pseudoparalytic. She's got significant weakness with external rotation and forward elevation, but she doesn't have a big lag. Her x-rays are pretty normal, right? So nothing really too concerning. There's no surprises here. Hamada type two, but her head's not proximally migrated. But then when we look at her MRI, it's a little bit more concerning, right? So this is the patient that, you know, I spend a lot of time looking at. They've got some proximal migration lying down in the gantry on the MRI, but not on x-ray in a standing position. We've got a big tear. There's a little bit of tendon just lateral to the tuberosity, but we've got that coutelier, you know, probably three change. So in this patient, you know, years ago, I would say we're looking at a reverse or a graft as I'm having this conversation with this older patient. But now the first thing I do is I look for her biceps on her MRI, and if her biceps is intact, I have a very different conversation, right? Because 66, Medicare patient, right? So in this country, you can't overcharge, you can't charge Medicare patients out-of-pocket expenses, and now you're talking about putting on any of these grafts you've heard about today, whether it's, you know, a bio-inductive scaffold, is it dermal allograft, is it, you know, a PLLA scaffold, is it collagen? Every one of those things is thousands of dollars, and if you're trying to do this case in your surgery center, you just lost money. So now you're moving to the hospital, dealing with inefficiencies at the hospital, so your whole life has changed how you're gonna manage it. When I look at this patient, her biceps is intact, I don't have that conversation. I know I'm gonna use the biceps, and the question is, is which one of the three ways you're gonna hear about right now, do we use it, right? So the problem that we're dealing with is these patients are at high risk for recurrent tear. Is it really a recurrent tear, or does it just never heal in the first place, right? Are we in a situation where we're dealing with failure? We've got chronicity, we've got stiff atrophic tissue with poor blood supply, poor biology, and as we deal with older individuals, particularly if they're smokers, we're at risk for poor healing. So we've gotta do something different. When we're dealing with large tears, they undergo this metaplasia. They have fewer fibroblasts, fewer blood vessels, and fewer inflammatory cells, and so they're more likely to fail. So if you go in blind and you just do a standard rotator cuff and margin convergence, it's not gonna work out very well. When we see these tears that have had some chronicity, right, when they tell you they've had pain for six months, somebody's given them two cortisone injections already, these are at high risk for failure, and you need to be prepared to do something different. Have the conversation about reverse, but where I live in LA, my patients are super active, and they're not really interested in reverse, and you even tell them, your recovery's gonna be faster, you're gonna be out of the sling quicker. Doc, I don't want it, what else can you do? And so this is one of the things that we think about now. So augmentation for me are revision cases, any massive tear, or what I call the tear at risk. So if it's retracted more than two centimeters, if it's got chronicity, if it has guttality A changes, that's when I'm gonna look at it. I think Kwan's helped us a lot with the Rohy score, right? So it tells us, who do we really need to think about this, and when do we bring it into play? So if your patients are older, over the age of 70, you get two points. If it has retraction, you're getting points. If there's fatty infiltration, so this has really helped us, and two smart, really smart guys, Pat Denard and Ashish Bedi, have given us an algorithm that helps. So if your Rohy score is getting up to seven, then you better think about using something, either a graft or a patch, or the biceps in some capacity. And can we improve our outcome if we're using this biceps autograft for augmentation? We got lots of biologic graft options. You've heard about them over the course of the last two days in several different options. But we're gonna focus on the biceps autograft as this top prospect. So we wanna improve biomechanical strength in biology and close the defects. And the advantage of the biceps is it's there. It's easy to use. It's free. And often older patients will allow you then still to be able to do this in your surgery center, and it's less technically demanding than passing a graft, and you can use your existing rotator cuff repair for fixation. Biomechanically, it's been shown to improve function. It prevents superior humeral head translation, decreases that acromiohumeral contact pressure, which again can help with successful outcomes and less pain. And it helps decrease the deltoid forces for abduction. So there's a lot of positives here. And Pat Denard has shown us that it can be significantly thicker than using that super thin biceps dermal allograft that works well. What's the disadvantage? There really aren't any. If it's there, let's use it. There's a perceived notion that not addressing the biceps with a tenotomy or tenodesis will leave it as a pain generator. But in my experience, it hasn't really happened. And I think that's what's delayed the popularity, but we're starting to see it happen now. So for me, I use it in these older individuals that have an intact biceps, and I rarely have that graft conversation. It allows me to do these bigger cases in the ASC and continue it as part of my day. My partner, Dr. Snyder, in his last few years, he really didn't understand why we were cutting the biceps from the superior tubercle. So when he did a tenodesis, regardless of what was going on down below distally, he left it intact at the superior tubercle. He just tenodesed it in the groove. And so what he was essentially doing was an anterior cable reconstruction. And he did this routinely for several patients. And so our fellows went and studied it to see, are these patients doing any worse than anything else? And so simple technique, it's a triple loaded anchor placed about five millimeters posterior to the biceps. We pass what we call an Italian loop suture, and then we pass that same suture through the rotator cuff again, and then use your standard second and third sutures like you normally will. So this is what it looks like. So we're looking at this right shoulder. I'm gonna basically just rough up the groove right underneath the groove, and you can see the biceps is a little ratty. In the old days, we'd say that's a tenotomy or a tenodesis, now we keep it. And then what we would do is just debride any of the fraying that's present, but you can see we've got a big rotator cuff tear here. And so what we wanna do is prepare our tuberosity, like you've heard me talk about, right? We're gonna do our crimson duvet under the biceps, as well as under the top of the tuberosity to basically set ourself up for healing and success. And we're gonna go ahead and make our microtubule microfracture holes to allow us to secure this in position. You're then gonna put your suture anchor into position, and what we're gonna do, we're looking from lateral, and we're working from the front. So we're gonna use a curved suture hook here. We're gonna come through the rotator cuff, and then we're also gonna penetrate through the biceps tendon here, okay? And we're gonna use a retrograde passing technique here. So we're gonna go ahead and retrieve our suture, pass it through the biceps, and then we're gonna pass that same stitch a second time. So this is what we call an Italian loop. It's something that we worked on when Alex Castagna was visiting us. And what we do is now go through that rotator cuff again, and then again, you just wanna lift up on it, and you wanna make a second pass through the biceps. So it's kinda like doing a loop suture if you're doing an all-suture-suture anchor tenodesis repair, and we're gonna pass that same stitch again. Now, most of the time, you can't tie a sliding knot. If you're gonna do this, you have to tie a static knot, and you can then go ahead and secure this, and this is gonna give you an anterior cable reconstruction for that front part of the rotator cuff. So if you have an L-shaped tear, this is a great option, and then you can continue to repair your rotator cuff in a standard fashion, and here's what it looks like. We just march along, like we talked about earlier this morning, and this is a single row technique. If you wanna do a double row over the top, you certainly can, and then we microfracture the tuberosity, and there's our healing elements with our crimson duvet to help get this thing healed. And so it's a nice technique that works very well. We've studied this, our ASES scores, 94, our visual analog, they don't complain of pain, and we've studied also with ultrasound, and the biceps is intact 27 out of 28 times, and none of these patients have required revision surgery. So I think that this is a great technique for these massive cuff tears. I think you can augment with dermal graft, but it's technically difficult and expensive, and probably takes you out of the ASC. The biceps incorporation is readily available and easy, and our results seem to hold up over the traditional SCR, which you're not hearing much at all about at this meeting today. So I think it's a viable option for these difficult patients. I appreciate your attention. Next, we're gonna hear from Larry Field, who's gonna talk about the next stage of this, which is moving it out of the groove, and how you manage it that way. So Dr. Field's time slides. Thank you. Thank you, Mark, and I agree with a lot of the indications that Mark referred to for utilization of the biceps, and I think there's just a lot of ways to use the biceps, and hopefully some of the points I'll make not only parallel what Mark has said, but some options for utilization of the biceps itself. My disclosures can be found on the AOS website. So as we know, the rotator cuff massive tears are very retracted. They're often very inelastic, and a lot of these can't be completely repaired anyway, and there are a lot of techniques to augment it. The bridging grafts that Mark talked about, SCR, muscle transfers, and more recently, as we know, this biceps utilization, and there are some studies that different techniques, lots of publications recently showing different techniques for biceps transfer and transposition, and this study actually showed that after utilization of biceps as an augment for massive tears, that they can actually lower the humeral head, which we know can potentially be valuable because of the superior humeral head migration we often see. These two biomechanical studies, the question is can the biceps tendon be used to reconstruct the superior capsule? These studies both suggest that it might be able to. It restored shoulder stability in both of these cadaveric models, and was found to be the biomechanical equivalent to tensor fasciae latae autograft in the prevention of superior humeral head migration. Anna, we're at Anna meeting, and I saw this in the newsletter, a recent newsletter publication by Anna. Dr. Zichilli remarked, and it's titled, Waste not, want not, is it time we move the biceps tendon out of the trash and onto the greater tuberosity of massive tears? And the article quoted a surprising contender for the spotlight as a graph source, what they're referring to, and this talent search is the biceps tendon, a structure that many of us have spent years releasing and repositioning, and recent literature has exploded with reports repurposing the biceps tendon, and it's really true, if you look at the literature, with various techniques to use the biceps to augment massive rotator cuff tears, and all of these articles, or many of them, in the last two or three years. So there are lots of different ways to do it. I will tell you, just a 35,000 foot view, when you read these articles, the great majority of these articles show benefits to utilization of the biceps in this clinical setting. We published our technique about four years ago. It's really, all we really did was we just mobilized the biceps out of the bicipital groove, and we moved the biceps to the greater tuberosity. We didn't cut it proximally. We didn't cut it distally. We just moved it and secured it there, and we thought that might be good because it would serve as a convergence post. It was in line with the superior capsule fibers. We hoped that it would offload the repair construct because you can sew to the biceps in that position much easily, just as you can with Mark's technique that he just showed, and we coined this term bioSCR mainly just because it's a local vascularized graft and its potential role in superior capsule reinforcement. So it's just an example of a case we used it in. This is a left shoulder beach chair position. It's a 54-year-old laborer, actually, and he had, I'm sure, a chronic tear that got progressively worse because of a relatively minor injury, and you can see that the cuff won't lateralize even back to the most medial footprint, and this is what we often face in these massive tears. So there are techniques that we're all familiar with, anterior interval sliding continuity, and in this patient, I'm doing a capsular release. This is posteriorly, and I come around posteriorly and then posterior inferiorly, and you'll see here that I did quite an extensive release, really all the way around the shoulder, and what that gets us is it gets us some increased lateral excursion, but in my experience, it's only about a centimeter or so, typically, that we can gain with a capsular release like this. So we're better, but we're still not very good. So another thing that we commonly do almost in all of these patients is we medialize the footprint to some extent. It just basically means we remove some articular cartilage from the most lateral cartilage of the humeral head. It gives us some more braided footprint that we can sew to, and after we do that, then we mobilize the biceps. We move it over to the greater tuberosity, and in this particular case, I've considered this a partially repairable cuff, and so in that situation, we place the biceps into wherever that residual defect is gonna be, and we just use standard anchors. We secure the biceps in this position, and you can see here, we just pass our standard suture anchor sutures through and around the biceps to secure it in this spot. Once that happens, once we complete this transposition and securing of the biceps in its new position, then we just proceed with our standard rotator cuff repair, and in this case, we'll repair the anterior component of the tear to the anterior greater tuberosity, as shown here, and the posterior component to the posterior tuberosity, but also, again, it's importantly, we can tie the rotator cuff to this biceps tendon. Remember, this biceps tendon in this situation is normally physiologically tensioned, so there's still tension there. You can pass sutures through it, and you can hopefully offload this repair construct. There's an anterior interval slide in continuity, our intact subscapularis, and it's repairing. Again, note, the biceps has just been moved. We didn't cut it. We just left it just like that. As another example, I think I'm gonna show here that this one is another massive retracted tear, but we really considered it completely repairable, but we used the biceps anyway. We moved it to this greater tuberosity location. We passed our sutures. We tied our knots, and here's this completed repair with this transposition of the biceps. Now, mobilization of biceps, people ask me. It's actually quite simple. This is a different patient, but you see, I just use a standard arthroscopic shaver. I just release the transverse femoral ligament, and importantly, from a technical aspect, it's important to release it all the way down, all the way like that, so it's completely free, and then you can just take it, this biceps right here, and just move it right over. We just reported an arthroscopy journal, 30 consecutive patients we used this procedure on. No patients were lost to follow-up. The mean age was 67 years. Half of the patients were completely repairable. Half were only partially repairable, as I alluded to, and post-operatively, ASCS scores and VAS scores improved. Active forward flexion improved from 120 degrees to 157 degrees, but I wanna highlight that, because these patients had 120 degrees of active forward flexion preoperatively. These weren't the pseudo-paralytic patients. Those reverse candidates. These were patients that were functional, had pain and some weakness, and that's why they had rotator cuff repair. There was one complication in our 30 patients. Another laborer who had a long head rupture about six weeks after his operation. We did an open subpectin adissis on him, and it gave us an opportunity to scope his shoulder, and we saw that the rupture had occurred just distal to where we had secured it, and that the more proximal tendon was incorporating, and the patient went on to recover uneventfully. More recently, there are comparative studies, different techniques, again, using the biceps, but this study showed 30 partial repairs with and without use of the long head of the biceps. Retail rate was significantly reduced when the biceps was added, and when the biceps was added in these 30 patients, they had improved outcomes and increased acromiohumeral distance, importantly. And another study recently published as well, over 100 patients comparing arthroscopic repair with and without a biceps tendon augmentation, and at two years of follow-up, the long head biceps group had improved function, motion, pain scores, and a significantly lower retail rate of 14% compared to 46% when the biceps wasn't used. So in summary, I think the biceps, as Mark and others have said, is a valuable augment in massive tears using a variety of recently published techniques. There are, we feel, some potential advantages to this particular technique that we use. Again, normal biceps tension is maintained, so it's a really excellent convergence post. You can tie to it quite well and easily. The intact biceps provides a static and I think potentially a dynamic humeral head depressor effect. It's biologically viable autograft. It's in immediate proximity. This technique of transposing the biceps really takes us five minutes or less. You just free the biceps, you move it, you put an anchor there, the end. And as Mark said, and importantly so, the biceps is quite thick. It's six and a half millimeters in diameter, and that's, and we know that the thicker the grafts from the SCR literature, the better the outcomes. And so this is thicker than almost any commercial graft available for SCR. There's reduced anchor requirement. Because of this, we can, again, sew to the biceps and reduce costs. We did a study, look, comparing the ASC costs at our ASC with humeral dermal allograft, or SCR versus this, and we saved $4,000 per case. So that makes your administrators quite happy. And we've used this technique much more liberally over the last couple of years. We've done it approximately 90 additional cases and have not seen any unanticipated or untoward complications related to the biceps. So thank you very much. So, you know, now we're going to switch gears. So some people still may be uncomfortable leaving it attached. So we're going to now talk about doing a standard technodesis and doing our bicep smash technique. So Kevin. So, I'm actually going to give this for J.T., who's initially going to be with us. So, J.T. was nice enough to share this talk, so I'm going to help go through this. So basically, we're not going to go through this too much, I'm going to speed through the front part. But basically, the problem is, as we know, that despite all of our improvements over the years, that actually our rotator cuff success rate is really not going up that significantly. And obviously, there's the holy grail with looking at mechanical strength with rotator cuff healing, with biologic growth factors, and everybody feels that sort of the holy grail is can we increase and get the biology to help improve our healing. You know, as Mark said, we know the Rohy score and all the different factors related to that. So I'm going to go through here, and sort of the purpose of this is just to show you that, you know what? We can do better when it comes to rotator cuff repair, and the question is, what can we do better? Here's just an example, 59-year-old male, and failed conservative treatment, spent a lot of money on different things, including PRP, despite the fact that he was working a maintenance job. A lot of these patients spend a lot of money. So there's different graft options, and I won't go through all these, but there's xenografts and different types of grafts, and the question is, do they work? And some studies show that they can work, but when you actually look at it, and the fragility index of some of these studies, that actually if four of the patients would have had a different outcome, the statistical significance would have disappeared. So you know, the issue is, with some of these patches that we're using, do they really work, and how well do they work? But there's no question that we need to do better, and we need to try to improve on our rotator cuff healing. There are definitely issues with xenograft clinically. And so this gets to the argument about, again, autograft patches. Can we use the autograft biceps, and if so, what are the different ways to do it? And you just heard two eloquent talks with Dr. Gettleman and Dr. Field regarding different ways you can use your biceps. This is actually a different method. So this is a method that JT came up with and actually presented on, and actually they won the award for looking at their tenocyte viability. So basically the premise is, you take the biceps, you do a tenodesis lower in the groove, but you have excess tendon, and then can we take that tendon and actually use it as a scaffold to augment the repair itself? And initially, they actually tried to do this using basically the same way you do a skin graft mesher. And initially, they tried doing that. And so, JT initially looked at the biology of it. He goes, well, if we smash these things to try to make it into a graft, are we going to be killing the tenosites and should we even be doing that? So he basically did a study looking at smashing the graft and does it act, does the compression actually kill the tenosites or do these tenosites prevail and heal? So does the smash technique where you actually compress it and you can take the proximal portion of the biceps and smash it and make it into a graft, how much damage is it doing? They actually looked at the tendons, those that are smashed, they segmented and looked at the viability of those tenosites. And actually, the results showed when you compared the two that the tendon itself, and this is the half that actually gets compressed, 93% of the smash samples showed no evidence of tenosite damage. And so, there was really no significant difference between the two. So you don't kill the tenosites by doing his smash technique at time zero. Let's see if we can get this to play. So this is the basic bicep smash technique. You may have seen this, do this earlier today, utilizing the biceps tendon. So the first thing he's going to do, he's going to do a low tenodesis. So he's just going to do an onlay tenodesis distal with a simple suture. And then that residual proximal tendon, as opposed to what Mark and Larry showed where they're going to actually keep it attached and use it, JT has taken that proximal tendon out and he's actually going to use this basically device where it compresses, smashes it into a graft. That takes a couple minutes to do. And then he's going to use it and deliver it. And very similar to the way we're basically incorporating other collagen-type grafts into repairs, that's basically the same way he's using it. He's using a repair technique here very similar to actually meniscus repair. And here he is placing the stitch posteriorly. And so this is his technique where it's obviously cheap. Your ASC is not going to, you know, have a fit regarding the cost. You're using the proximal tendon. But you're actually, again, he showed significant, he showed that he's not killing the tenocytes by doing this. And he's smashing it into a graft and he's using it. And here he is fixing it. He'll usually put it up in the two corners medially and then he'll fix it laterally as well like we're all used to doing with our double row repairs in the lateral side. Those people do do double row transosseous equivalent techniques. So here's the end result. So that's the tendon that JT is utilizing to augment his rotator cuff repairs using the quote unquote smash technique. So the question is what happens to the graft over time? He's looked at this with early results looking at MRIs. And basically it does incorporate over time. He actually showed this earlier today so I'm not going to go too far into it. But you can see it at six weeks. And at 12 weeks it doesn't look great. But at 26 weeks it's looking better and better and better. And that's often what happens with MRIs. He looked at does the patch actually augment healing. And he basically looked at these patches postoperatively. And both with full thickness as well as partial repairs. And he showed a potential, potential at early follow-up significant benefit in the group that he looked at. So again, smaller numbers, short follow-up. But very optimistic in terms of some of the results that JT has been showing. He's also been utilizing it for his subscap repairs with total shoulder replacements as well. He's done 20 of these. No significant clinical failures. And he's looked at it at ultrasound. So his early conclusions, and I know he's been working on this for a while, is the fact that the biceps autograft can be used as a local available cost effective option. It's free for rotator cuff augmentation. There's different ways you can fix it. And basically it can be robust, reproducible. And it does not compromise tenosite viability based on their work that, again, they just won one of the awards today. And potentially in the future they may show with longer follow-up this augmentation may decrease retear rates and increase tendon thickness with partial repairs. Certainly further study is warranted, but it's actually very, very interesting. And we look forward to seeing more of his work on this. But it's a very unique way to utilize the proximal biceps in a way that is a little bit different than the way that Mark and Larry showed with their technique. So not that one way is the correct way, but this is a different way that I think has, you know, a lot of potential. Thank you. All right. So the last thing we're going to talk about, and we'll take some questions afterwards, is what do you do when it goes wrong and you have complications? And so it's always good when you have the youngest person on the panel do the talk on the hardest technique. So we're going to invite Dr. Gregory to talk to us about complications. Yeah. So the lack of gray hair probably shows some of the lack of complications I've had with the biceps so far in my career. But thankfully, I have an awesome panel who can help add in their tips and tricks as well. So I'm looking first, no conflicts here, but looking first at kind of what we know. And not to belabor this, so kind of the tenodesis, tenotomy question. Obviously, these are both great procedures to address pain from inflammation or instability. You know, the use of tenodesis in our younger athletes for slap tears and things like that. Certainly all well-regarded surgeries that provide us with successful outcomes, both subjectively and in terms of our return to sport, even in our younger athletes. But of course, like all surgeries that we do, complications exist. And they range from those cosmetic ones, so those Popeye deformities, even wound healing complications, scars that aren't pretty in the axilla, to the more catastrophic complications that we all hope to never see in practice. So as we know, kind of these, the complication rate can vary, you know, typically on the lower side. Some studies reporting higher, but somewhere in the, you know, the range of 0 to 20%, depending on how big the series is. And you know, the cosmetic deformity, the Popeye deformity, we're all concerned about probably, you know, in my neck of the woods in Texas, the Texas mediums aren't so concerned about the cosmetic deformity. They've not seen their bicep in a while, so probably for them it's not as important. But in our higher level athletes, or those patients that are really concerned about the cosmesis, this can be a big issue for them. Of course, biceps tendon rupture after a tenodesis is a huge complication. And then those more catastrophic complications, the neurologic or vascular injury, the humerus fractures. And of course, any time we have to go back and operate on someone again for a complication related to something we did is a major complication. Looking a little bit at kind of the arthroscopic versus open, we've just seen today that outcomes can be pretty similar. It's kind of a dealer's choice, choose what is best in your hands and go from there. Possibly a little bit lower risk of humerus fracture with arthroscopic versus kind of a sub-pec fixation. If you're thinking about kind of putting your anchor or your interference screw or anything into the hard bone of the groove, that part of the bone that even in your four-part proximal humerus fracture, it's still there, that's good bone versus lower below the pec where you're almost getting metaphyseal, it's a little softer. In some of these older patients, even an interference screw, you don't always feel the best about leaving it there. So consideration to have. Of course, advocates of open sub-pec as we've heard, biceps groove pain, biceps groove pain, you got to get the biceps out of the groove. That's the reason that patients still have anterior shoulder pain. And then, of course, on the other end of the thing, on the spectrum, the arthroscopic group says, hey, even if it fails, you still have that whole chunk of tendon available for you for your revision tenodesis. It hasn't gone anywhere versus your sub-pec, you may have trimmed most of it out and left yourself with a small stump. And then in terms of combining any sort of bicep surgery with your other common procedure you're doing, your rotator cuff repair, no difference in outcomes if you're kind of doing a tenodesis or not. Wound complications, as we know, the axilla is not awesome, lots of bacteria grow there, and you can even have osteo, things like that, that develop in a delayed sense. So a couple studies, we'll kind of breeze through them. So no difference, that kind of mid-term outcomes for both super-pectoral and sub-pec, and this had very little failure or major complications reported in this prospective study out of Rush. Another looking at a big, a systematic review, a couple of these out there that look at kind of the tenodesis versus tenotomy, and interestingly, as we know, the cosmetic deformity, but, you know, amongst this study group, one study showed actually improved supination steric tenodesis, and another showed that there was more cramping with the tenodesis group. So once again, a little bit of a mixed picture, probably not the ultimately important thing, especially when we're considering all these other uses for the biceps. And then a little bit of what we haven't talked about today, the management of these younger athletes. So using your biceps tenodesis for your slap tear patients, and in this group, we can see that there is a lower revision rate in the biceps tenodesis group compared to the slap repair group. The good news is if your slap repair does fail and you go in to revise it, either re-repair, you still have that biceps tenodesis option available for you, and in this study, no difference in return to sport, depending on whether you did a repair or a tenodesis. So re-operation rates, in the young patient population, a pretty low re-operation rate in many studies, but up to 17, 18%, and a few likely kind of this mixed bag picture is that just from the slap repair that you did versus the tenodesis, it's a little bit of a mixed picture. But in particular, in some of these patients, the repair is a little bit higher, and then if you're addressing this in the younger patients, no difference in tenotomy or tenodesis. And then of course, as we've heard today, lots of other uses for the long head of the biceps. Of course, we've heard about the viability of the tenocytes, the biomechanical strength at time zero that can help us augment these tissues that have poor healing capacity. And then of course, kind of the ability for that biceps tendon to mimic the demands and the load of the surrounding soft tissue structures. So we've heard about an augmenting rotator cuff repairs, and this bio-SCR technique, we haven't talked a lot about its utilization in glenohumeral instability, but that's coming next. A lot of newer papers looking at how, hey, we may be able to use this biceps to either reroute and use it as a local autograft, or even in a recant to augment your anterior capillary laboral repair, or even as a reconstructive technique if you have a little bit of an atrophic tissue down there. So keep your eyes out for those studies as they're coming out more. And then, you know, when we think about this, what are the complications? The good news about new techniques is the literature is full of ways to utilize them, but we don't really have great, big, long-term studies about what the complications are. Good news is very few so far. A little bit, as we would expect, Popeye deformity is the number one thing that's been reported, but it's rare. And then, you know, secondarily, kind of those other shoulder surgery issues, adhesive capsulitis, and then in these arthritic patients, in one study, a conversion to an arthroplasty, which, you know, I think is a fair, you know, assessment for the age group rather than the technique or the use of the biceps. So in terms of treatment options, why we're all here, I took this a little bit dogmatically once again, not having, thankfully, experienced that many of these in my practice myself. But of course, when we have a cosmetic deformity, a Popeye deformity, what are our options? Number one, do nothing. Really. I mean, a lot of these patients don't even notice. In several studies, the surgeon identifies the Popeye much more readily than the patient does, and they may or may not even notice that. Of course, there are, you know, those manual laborers, the ones who use their arm and use that supination strength are going to notice, they're going to have the cramping. But for the low activity, middle-aged patients who are desk warriors, they may never notice. So doing nothing is a reasonable option. In the failed slap repair, as we've talked about, tenodesis is there for you. That's your bailout option. You have that, you have that, whatever, whatever choice you may, whatever fixation choice you may have. And then, of course, the revision setting. So revising your biceps, tenodesis, that has failed. If arthroscopic, good news, you have tons of tendon left. You can bring it down, do an open subpec. If you have an open subpec, it's a little bit more challenging depending on if you used an interference screw or an onlay technique. I think with the onlay, you do have a little bit more tendon available to you, especially if we're having those type 2 tears with an interference screw where it's tearing kind of distal to your interference screw. And then you don't have much you can use in a graft here if the patient is really concerned about it. So once again, it's kind of knowing what you're dealing with before you go in for that revision. And then, of course, just like in the rest of orthopedics, the other bad stuff, you fix what's broken. If you really did fracture the humerus, you fix it. If you have an infection, you deal with it. And then, of course, if you have a neurologic complication, you do everything you can to hope and pray and really hope that that nerve comes back and then address anything further as it happens. And then in our newer techniques, the good news is the use of the bicep really doesn't burn many bridges. Maybe you use an extra anchor. Maybe you're dealing with that if you're an arthroplasty surgeon and you're trying to deal with anchor load in the head and getting fixation. But beyond that, your options are pretty simple. Re-repair if you think the tissue quality is good. If they're a young patient and they're not ready for an arthroplasty, are they a tendon transfer candidate? Is there another graft option? Are they a formal SCR candidate? If they're older, arthroplasty is there as well. And then, of course, in the failed instability surgery, depending on what the rest of your algorithm is for that patient, if you've tried to use this as a way to save them from a big bony procedure, thankfully, you also have that available to you. So good news about the bicep. It's locally available. It's readily available. It doesn't cost the patient anything. And we don't really burn any bridges if we use it. So how do they do? If we actually have one of these revisions, if we have to revise their biceps tenodesis, how do they do? A couple of studies looking at this with kind of lower size case series since there aren't that many that publish this. But good news is, although they've gone through a second surgery, generally they do great and have really good PROs and patient-improved or subjective outcomes on all measures. And most of them report that they would have the revision again if they've gotten to the point where they want to. Thank you. And now, hopefully, these guys will tell you their worst complications. All right. Thank you. So we've got about ten minutes left. If there's any questions from the audience, happy to have them. There's a mic here. Anything? Yes, sir. All right. Yeah. So I think that's a great question, right? So your standard rotator cuff, you've got, you know, one centimeter tear, relatively, you know, good muscle, and you get in there and the biceps is frayed. What do you do? So in that case today, I will still do a standard, you know, tenodesis. So that's what Dr. Bonner talked about earlier. We've actually recently developed an anchor that's on the market, which allows you to have a socket, and so release it at the tubercle, repair it, and then do the biceps distally like you normally would. It's the tears at risk where I think that these other techniques come into play. And if the biceps is normal, I leave it alone a lot, right? So because if you think you're going to be in a situation where that biceps can fail, and I've seen it ten years later, I've had to go back and do a revision on somebody who had a tear repair ten years ago, and then we left the biceps alone, the biceps was still sitting there, and it's funny that the bigger the tear, the more likely the biceps is to be intact, because I find that it tends to hypertrophy because of the stresses that are being placed upon it. Now that's level six evidence, but I think that, you know, when you see these big tears, oftentimes the biceps is still there. Larry, question. Somebody asked me the other day on the bio-SCR, why don't you make a new groove over the top of the humeral head to sit it in the groove versus just suturing it in place? Yeah, you know, that's a good question, and there is actually a recent study of individuals who did just that, they created a recess to bring that over. I just, we've talked about doing that, I've not done that, I just, I like the height, the bulk that it gives me, it simulates that superior capsule reconstruction graft, and that fullness that you get in a several gram space, I think is probably valuable, I can't prove it at all, but we haven't seen any consequences related to that, but it's a reasonable technique that's been published and had good outcomes. Can I ask actually both Mark and Larry a question regarding decision-making, very similar to the earlier question. So from a decision-making, if you get in there, you have somebody who has a chronic cuff tear, not getting better, you're going to go in and do surgery. What about that patient that says, you know what, I hurt right there over their biceps, you get in there and it's beefy red, it's not minimal, it's beefy red, how does that impact what you do? Yeah, I'll just take that first. In our study on this BioSCR we reported, we intentionally ignored the status of the biceps on the theory that in this clinical situation, it's bad, we got a huge tear, we got, you know, bad tendons better than no tendon at all is the way we looked at it, and we did not see any negative consequences or significant residual bicep symptomatology even if they had preoperative symptomatology. So my personal feeling about this is that when you do a tenodesis, no matter how you do it, if you secure it to the humerus, you've stopped the translation. We know the biceps translates about two and a half centimeters through the bicipital groove. I personally think that's really all of the pain generator, the instability medial lateral or the translational pain, like a decrevains, for example. And so when you stop that translation, you stop their symptomatology. And so that's just my general gestalt of it, and that's how we manage these patients. So to answer your question, I just ignore the status of it. I just do what I'm going to do with it and go down the road. So Bonnie, now we've got a younger patient, let's say they're 56, they have a big tear, there's some atrophy, but now the world's your oyster, right? Because now their biceps is still intact, but you're in a situation where you can use a graft as well. Where do you have that conversation with the patient? How do you decide that you're going to talk to them about a graft, are you going to talk to them about a biceps, or what else are you going to do? What's funny is this talk is actually leading me to think some different things. I'm in an academic setting, I do a lot of my cases at the hospital, and I've never once had a graft I've used, an implant I've used, anything be questioned, just based on my practice setting. And I've frankly like probably thrown out or cut a lot of biceps that I could have been using. I think, you know, you see one of these, you know, either they have an upper bar or subscap and they've just been debriding this biceps and it just looks terrible and you can't fathom that it can have any use. But now I'm going to start incorporating it, especially for the kind of anterior cable portion of it, for those anterior tears where they've torn that, the anterior supraspinatus, they're into subscap a little bit. And that's the tension area. I think rerouting it and using it as that cable, I think is awesome. And I've done that a little bit, but I'm now going to use it a whole lot more than I have been. Yeah. So I think the other thing that we don't talk about a lot that we need to think about is getting paid for what we do, right? We get paid the same to put one stitch in a side to side subscap as we do in a four anchor massive rotator cuff. And I don't know about you guys, 22 modifier doesn't pay me a dime rarely, right? So we get paid the same thing. So doing things that are going to help improve our life, that it can have a similar outcome. To me, this has kind of changed the mindset because you're sitting there going, all right, I repaired this rotator cuff. It was a repairable tear. It's kind of thin. It doesn't look great. Do I want to go spend another 30 minutes now to put a dermal graft on or 15 minutes and $6,000 to put a bioinductive scaffold on? I mean, these are real decisions that we're making every day in your OR, right? So Kevin, you got a busy OR day. How do you decide who gets it and when is it the right choice? Yeah, I've, and believe me, my surgery ASC partners look at every case and what you spend. And believe me, there's chatter amongst who's using what. It goes on all the time for us. So I try to be very conscientious with grafts. I actually do not use that many collagen augmentation patches, quite frankly, in my practice. I've been going more and more to doing, honestly, Larry and Mark's technique and utilizing that biceps when needed. That's something that I didn't do three years ago. So I think that's been very, very valuable and something that's changed my practice. But I'll be honest, I do a lot of partial repairs, biceps, tenodesis even, and a lot of those, and Larry's published on this, a lot of them can do very, very well. So, and we talked about this earlier in one of the sessions, that that's sort of the standard, doing a quote-unquote partial repair, debridement, plus-minus biceps. You know, we start talking about all these patches and SCRs and everything. There's a lot of studies showing that that group of a partial repair debridement can do just as well as these expensive patches. So I do sometimes do a patch, but I do very, very few patches, quite honestly. And it's not just because of the economics of it, honestly. It's because of the fact that I'm still, I put the patches on sometimes, and I'm like, we start moving, then I'm like, am I really sure that's going to be on here 48 hours from now when you look at the fixation? So I do it, but I do patches very, very sparingly, and I think some of the techniques you heard from Larry and Mark can really change your practice. And for those of you who have ASCs, your partners aren't going to look cross-eyed at you. Any other questions? Yes, sir. I do rotator cuff surgery in the beach chair position, instability lateral, and in the beach chair position, typically we use a Tromano device, an arm holding commercial device, and typically the arm's positioned in about 30 degrees of abduction and 30 degrees of forward flexion, and there have been biomechanical studies that suggest that that's probably close to the best position. I think by default it ends up kind of being in that position is my point, so I don't look down and look like I'm doing a shoulder replacement, but I do, I am a little bit cognizant of the fact that, make sure it's not some crazy position when we actually secure the suture anchor suture. Is that for both the bio-SCR and the anterior? Well the cable, I'll let Mark answer that, I'm referring mainly to the bio-SCR. Yeah, so when I do the cables, typically when I move, I start in, I'm a lateral surgeon so I do all my cases laterally, I think it matters a little bit more. When I start my case and I'm intra-articularly, I'm in about 70 degrees of abduction. When I go to the subacromial space, I come down to about 15, and once I repair the rotator cuff, I go, you know, two clicks in general on my arm holder to what I call mid-position at about 30 degrees of abduction. So you don't want to do it with the arm up in what we call the, you know, glenohumeral position in 70 degrees, you got to get that arm a little bit lower because if you don't and you bring that arm down, you could get some tension mismatch. The biceps does, as Larry said, has about two centimeters of excursion, so it'll tolerate that, you just don't want it bunching up as you're going into forward elevation. But again, Dr. Snyder did it routinely, you know, for years and years and years on all his cuff repair and never released it in no complications. Awesome, well it is Friday night and it is happy hour, so thank you all for your attention. Please give us kind words so we get to be invited back to do this again. I think this is really an exciting new concept in what we're thinking about in rotator cuff, so appreciate your attention and thanks so much. Have a good evening.

Orthopedic surgeons

biceps tendon

rotator cuff tear repairs

biomechanical benefits

shoulder stability

biceps tenodesis

tenotomy

biceps augmentation

massive cuff tears

shoulder function

surgical approaches