So again, it's my pleasure to welcome you to ICL 304, Treatment Innovations for Massive Interoperable Rotator Cuff Tears. These are our disclosures. I personally have no financial disclosures that are relevant to this presentation. So I'd like to first introduce my panel. My esteemed colleague, Dr. Savoie, who is the chairman and professor of orthopedics at Tulane University. He's also the current president of the AOS and past president of ANA and ASES. Dr. Joe Abood, who is a professor of orthopedics at Rothman Institute in Philadelphia. Dr. Basim Elhassan, who is a professor of orthopedics at MGH. And I'm Peter Vaziridis. I'm in a private group called Excel Orthopedics just north of Boston, Massachusetts. So first, I'll give a brief introduction about this important topic. Dr. Savoie will then speak about his approach to evaluation and treatment, as well as all of his tips and tricks for success in treating his patient population. Dr. Joe Abood will speak about the subacromial balloon spacer. Dr. Elhassan will present on lower trapezius tendon transfer. And finally, I'll present the rationale for superior capsular reconstruction. Hopefully, we'll have a few minutes at the end for pertinent questions. So as we all know, treatment of massive and irreparable rotator cuff tears is a very challenging problem presented to us, especially in the younger active patient population. We all know that there are high failure rates after repair of these tears. And multiple surgical treatment options are available to us, thankfully, each with their own advantages and disadvantages. Thus far, no single treatment has been demonstrated to be the gold standard above all others. So we really need to tailor our approach to the patient and to their specific needs. So some of the patient factors, not entirely inclusive, but some of the patient factors that are important to assess are the patient's age, both chronologic and physiologic, the patient's activity level, social supports at home, their profession, the extent of disability that this tear causes them, any and all medical comorbidities, as well as any degree of joint arthropathy that may change our treatment algorithm for that particular patient. When we're talking about massive versus irreparable, well, the definition of massive, we have a couple of definitions for that. Coffield described it as greater than five centimeters in size, whereas Gerber described it as including two or more tendons. And irreparable, well, that definition is certainly controversial because while you can have a physically repairable or partially repairable rotator cuff tendon, the retear rates can be very high, up to 94%. And as we know, there tends to be at least a poor clinical outcome if you do have a physical retear of the tendon from the repair site. The clinical presentation can be highly variable, both in terms of pain, weakness, and active and passive motion loss. Some of these patients have a high degree of pain, a high degree of weakness, and notice a lot of weakness, whereas others do not. And the same goes for active range of motion. Patients, again, may complain of one or more of these symptoms, and it's important to hone in on which of those symptoms are the most limiting for the patient. And a lot of that depends upon, again, their demands on a daily basis and in their profession. So we really need to get to learn our patients, know what are the patient's needs, what are their goals, what are their goals for the treatment outcome, and how that will allow us to select the proper treatment for that patient. Imaging is essential, of course. Plain film x-rays will allow us to look for a degree of arthritis. Will also help us to look for the humeral head elevation, which we can measure by the acromio-humeral interval, as well as any acetabularization of the undersurface of the acromion bone. MRI, again, is essential as well. It lets us determine the degree of retraction, the size of the remaining tendon stump, as well as allows us to look at the guttale staging of atrophy of the rotator cuff. The Hamada classification has also been useful. As we know, you know, the more advanced we get as far as Hamada grade, the worse our outcomes tend to be for a joint-preserving approach. So if we're thinking about a joint-preserving approach, which is what we'll be focusing on in this ICL, we definitely wanna have a lower grade, grade one or two Hamada stage. Once we get to about grade three Hamada stage, then we tend to consider more potentially arthroplasty if the patient is a candidate for that. But again, multiple factors involved as far as the imaging is concerned. So what makes a rotator cuff tear irreparable, or what tends to make a rotator cuff tear irreparable? One, duration of symptoms. So of course, the longer the symptoms have been present, that tends to portend a higher risk of a tear being irreparable. Determining if they have an external rotation lag on exam. This does not necessarily portend irreparable cuff tear, but the higher degree of an external rotation lag makes us think more along the lines of, is this cuff tear irreparable? Decreased acromio-humeral interval with superior migration of the humeral head, particularly if that's less than seven millimeters. And of course, fatty infiltration of the rotator cuff muscles. So if we're looking higher stages of Goutelier, stage two and above, unfortunately we know that in the current day and age, this is irreversible. Maybe that will not be the case down the road, but at our present time point, we don't have the technology to reverse this infiltration. It's very important for us to also take into account restoring the forced couple of the glenohumeral joint, which is what many of these techniques that we have currently focus on and do. So it's always important to determine the forced couple and what is offset as far as what's deficient in the forced couple as a patient currently experiences. So as far as the treatment options, again, this is not entirely exhaustive, but we always attempt to do non-operative treatment if that's the right thing for the patient and if they can get by with non-operative treatment. However, many of these patients have failed non-operative treatment and need to consider something surgically. So as far as surgical options, debridement is one option. Partial repair is another option, which can give sometimes excellent results. Repair with augmentation. Then we're getting into more complex techniques such as superior capsule reconstruction and tendon transfer. The subacromial balloon spacer is a newer product on the market, which has some pros and cons. And then finally, reverse shoulder arthroplasty.

treatment innovations

rotator cuff tears

panel of experts

surgical options

glenohumeral joint