So, with that, I'd like to bring up Dr. Buddy Savoie, who will speak about his approach on this important matter. Thanks, Peter. Great fun to be here. It's one of my favorite topics, this massive rotator cuff tear, so hopefully we'll move on. I know it's here, I already checked it this morning, just so you know. All right, so a little bit of this will be maybe a little bit redundant. These are my conflicts and they're also on the Academy website. So the question that I would pose to you is, does an irreparable tear even exist, right? It's sort of like an unrunnable marathon. You can crawl the distance. You can make it happen. Evan Flaytell one time a long time ago said it's like being from the south and having an unmarriable cousin. It doesn't exist. So let's see. Let's back up a little bit. That didn't move. So what makes it irreparable? Size. If you know how to do releases and slides, going all the way back to open surgery, Dr. Neal would have said there's no such thing as an irreparable tear. And when you talk to people, if you know how to do a release open, there's no reason why you can't do a release arthroscopically so you can put tissue back. Tissue quality, you hear this all the time. I got in to repair it and the quality was poor. Well, it wouldn't be a massive tear if you had great tissue. So really that can be an issue, but we have lots of patches and graphs that can support this. So it would submit that that's not make it, that does not make it irreparable. Superior migration, if you know how to do a release, you know how to do an SCR, you know how to do a balloon, that is not a contraindication to repair. And even a partial repair so that you can put things back and restore your fulcrum makes that worthwhile. Atrophy. If any of you know how to regrow an atrophied rotator cuff muscle, that is what we need to be able to do. Because right now, those are the only muscles in the body that don't recover from atrophy. And if you have severe atrophy, then that may make a tear not irreparable but functionally irreparable where you would not get a good outcome. Now, the question is how much atrophy is too much and we'll address that a little bit at the end of the talk. Because we have the Gautier scale, I would venture that probably everybody in this room has fixed a grade four and had an excellent outcome from pain relief and function because grade four just means half the muscle is gone. And functionally half the muscle is actually pretty good function for most people in most activities. So, part one is let's fix it. How can you fix an irreparable tear if by definition it's irreparable? So, some of it is preoperative evaluation, get ready, try to get your motion back, releases in surgery to loosen up, try to balance biology and biomechanics. Many people think that it's more anchors for an irreparable tear makes sense. I would submit to you that's 100% wrong. You have to balance the biology which is what allows for the healing with the biomechanics to get a good repair. Extras are always helpful like you see here. Here's a patch and then something that we don't really focus on as orthopedic surgeons is rehabilitation and nutrition. By definition, if you have an irreparable tear and you're dealing with a patient that's not going to heal well, you should try to fix that as we go through it. So, preoperative evaluation, check motion, check for arthritis. Peter already showed you the Hamada scale. I think that makes a big difference. You want to do your exam for both passive and active range of motion. Most commonly, preoperatively, they have a loss of internal rotation. And if you have a loss of internal rotation and immediately afterwards, you start sending them to therapy, all you're going to do is push the head up against your repair and rip it apart. Not going to work out. So, know this ahead of time because you have to fix this while you're there. Radiographically, you want to look for, I don't know, a pointer. Look at your acromial humeral distance. Look for your critical shoulder angle. It's a subset that's attended by the face of the glenoid and the lateral acromion. Christian Gerber has taught us that. Look for arthritis because that may jeopardize your outcome. And then your MRI, look for the nerve. If you look at the bottom picture of the MRI and look at the suprascapular nerve just to the right of the glenoid, that's a bifid nerve with a lot of edema around it. That patient is not going to do well unless you go look at the nerve. So, positioning. Lateral beach chair doesn't matter. For rotator cuffs, it makes no difference. So, you do what you're most comfortable with. But you do have to be able to rotate the arm and you have to allow for inferior traction and the weight of the arm is not enough. You need to be able to pull the head down to put the cuff back together. So, intraoperatively, we want to continuously assess. We think biology from beginning to end. Release, release, release. Again, releases are critical if you're dealing with an irreparable or massive tear and you're trying to put back together what you can. Remember, we want to minimize the anchor. So, for us, if it's primarily just supra and upper infraspinatus, that's one anchor medially and one laterally. If it's subscaps involved, it gets its own anchor. If lower infraspinatus and teres minor involved, it gets its own anchor. And so, that's why you got to think about it. But once you do your releases, here we are. That becomes an irreparable to reparable tear. Releases, I keep alluding to that. I like to do a hook cautery because it's very precise. Now, the problem is that if you're a little rough-handed with your movements or if it's a little bit tight or you're struggling, that tip will bend. And so, you want to be careful if you use that and just acknowledge your own ability as a surgeon and use a side effect or something like that if you need to. But that's a tight capsule. I would submit to you with this capsule, if I tried to repair the cuff without releasing it, it would fail. It would go back to that 50% failure rate and you would go, well, it was an irreparable tear. I did my best and it didn't work out. And yet, something as simple as a release of that inferior glenohumeral ligament would give you a good result. We also release under the tendons. Apologies to anybody from France who's in here. I'm going to leave the biceps because I'm going to use it later and we'll talk about that towards the end of the talk. I do not routinely do a biceps tenodesis with, but I routinely use the biceps. And so, we're going to release under that supraspinatus. That's the edge right above the cautery. And same thing on the back. You can see stranding. That's a very bad infraspinatus. That's the edge of the tendon that you're seeing right adjacent to that. That's just bursal tissue above it. So, it's retracted to the glenoid. But by releasing the infraspinatus on the top and the bottom off the deltoid, I can bring it all the way back, even though it's retracted medial to the glenoid edge. Corco-humeral ligament release is very, very important. We're going to try to play it. Oh, let me back up. Let's see if that'll work. Can you click on the right one? If that'll work. So, the corco-humeral ligament cannot be released from inside the shoulder. You have to release it on the outside of the shoulder. So, if you follow the one to the right, we're going to come around the front. That's the base of the coracoid. That's the corco-humeral ligament that's been completely released. It has two bands, one to the supraspinatus, one to the subscap. If you release both those bands, and if you look on the right, we can now pull that head down. We've released it inferiorly. Joe Abood will talk a little bit on the balloon, and one of the things he'll say is that sometimes it feels like you've overstuffed the joint with the balloon, and it's having trouble pushing the head down. Release the inferior capsule. If you release the inferior capsule, the balloon doesn't have to try to stretch the capsule out for you. Balance your repair. We preserve the medial bursa. Let me say that again. If you're someone that likes to cauterize a lot and gets a lot of bleeding, cauterize laterally, save your medial bursa. We know from our basic science studies that blood supply to the rotator cuff tendon comes from the medial bursa. Save your medial bursa. Sew it into the cuff. You don't have to make it a special issue. Just save that, and then we know from Steve Snyder that we want to do a lot of microfracturing, and that's very important, and so if you have lateral thickened bursa, that's where your inflammatory cytokines, especially the mineral metalloproteinases that cause tendon to slow down healing, get rid of that, but cells come from the bursal tissue, so preserve as much of the non-inflammatory bursa as you can. Microfracture, create vascular channels. That's a two millimeter all. I have no idea if one millimeter, two millimeters, three millimeters are better. Do not know, so we kind of target it in the middle, and we do what we can, and then vented anchors. You need blood supply. We need critical zone. Cuffs fail because of enthesiopathic changes, so we try to change that. Anchor suture configuration is totally up to you, right? Do what you like. The thing I would tell you is that you don't want to really cross across the tendon, because blood supply, again, comes from medial, and if you do a stitch from anchor to anchor and cross your tendon, there's no blood flow coming to the distal part of that tendon. No blood flow, so it's not gonna heal because it's not getting blood flow, and maybe you'll get some healing from the bone up, but it's not gonna come from medial to lateral, so you have to create vascular channels. So as you see on this one, if you look, we have a suture, but just adjacent to it, there's nothing there, so that's gonna heal, we hope, by good blood flow. Margin convergence, I think, is very important. It's been talked about as being horizontal. It's not, it's as oblique as possible, so if you look across at this thing, because we wrote some diagrams on it, medial to lateral is how you do that. You do it in the same line of pull as the cuff, and you can take a cuff like this, which most of us would look in and go, yep, that's pretty irreparable. It's retracted medial to the glenoid, but we're gonna take one stitch through an accessory posterior medial portal, leave the biceps, because we're gonna use that to supplement our tissue. We'll put a stitch around it in a little bit, and then we'll retrograde retrieve a suture using the subscap so that we can put this back together. If you look at Hiro Sagaia's work, in many cases, the supraspinatus crosses the bicepital groove and in many cases, the subscap comes up over the bicepital groove, so if we hand this off and tie this down and pull this back, this massive irreparable cuff that's not gonna heal, you're looking at that bare humeral head, it looks terrible, and now we got a two centimeter tear that we can put back together a piece of cake. One stitch, no tension on the cuff, and now we've converted this irreparable tear to repairable. And so it's the same thing. Second stitch, you can do three of these and then put them in an anchor, you can cut them, it doesn't make any difference, but you're taking the tension off, and here we are using the biceps, just like you would an SCR, to pull that back part of the cuff back and over. And so we're gonna put all this down, and again, now with two stitches, this huge tear is now put back. Now we can add some more, we can do some more things, we can put it back down, but you can do as many as you want and put that back. Anchors, we all know this, and it's gonna be covered before, but you do sequential mattress stitches, we do retrograde retrieving, we'll retrieve through an advisor portal, so you just go around the corner and you put that all back together, and we need something like this where we have our vascular channels and put everything back in place and we'll check this. So what happens when you have this? We have options beyond the repair. So Peter's gonna talk about SCR, so we'll kind of skip over that, go pretty quickly, but there's some other things that I think are helpful. So the SCR, Tiro Mihata was the one that brought this in. He used the autologous fasciolata, really good results. It's interesting that he's gone from six to eight to now a centimeter of fasciolata to put in there. So I think the thickness of what you're putting in makes a difference. In the US, we haven't had as good experience with the dermal patch, so you have to figure out how you wanna do it and where it fits into your armamentarium. Remember that the SCR, much like a reverse, much like many things, is a biologic chance to push the head down and improve your anterior and posterior force couples, and we'll talk about that again in a minute. So JT Tokish, some other people have changed the fasciolata after having not as good of results with dermal patches. I did about 30 of these in the beginning, and then when I looked at my results, they were really not as good as the full repair patch, but what I will do is I'll take the biceps out of the groove, so if we have something like your top left picture, the right picture is pulling the biceps in, and then the bottom picture is using the biceps as an SCR. I decompress it, take the transverse humeral ligament out, take it completely out of the groove, and put it in place, put it on top of the tuberosity, so by taking it out of the groove, you no longer have symptoms. The question that always comes up, do you tenodese it separately? When I first started doing it, I would move the biceps, sew it to the top of the tuberosity, and then tenodese it more distally and cut it, and then one time I forgot. I just said, biceps, everything looked good, my cuff was fixed, I thought, this is great, and everything looks wonderful, and I finished, and I went out to dictate, and I'm dictating, and I realized, oh, shoot, I forgot to cut the biceps, so I told my patient, I said, you know, we have to come back and do something with the biceps. She did better than the ones I did with the tenodesis, so then I went, well, let's see how this works, so I did nine more. My rule of when I think of something is always do 10 and see how it works. I did 10 more without tenodesis in the biceps, and they did better than the ones where I did a separate bicep tenodesis, so now I don't separately tenodesis it. I think just getting it out of the groove all the way down to the pec makes a big difference, so that's what we do, and we looked up a big series of it, but other people were publishing on it, so we just let it go. Collagen vascular patch, we wrote a paper on this with Stephen Thon as the lead author. When it came out, Des Bakker did that because he's a complete, when he does a partial tear, he takes it down, completes it, and puts him back. I don't do that. I do partial repairs, so we thought, because this is actually not structural, it's just for vascular status. It improves your circulation to the cuff, so it can reverse, at least temporarily, the enthesiopathic changes in the cuff, and so we did it on revision cuffs, massive ones, and actually increased by 10% our healing rate with our massive cuffs. It went from 86 to 96% healing rate, so we think that's a viable thing. I think there are another, it's been about five or six years since we've been doing it, so there should be better stuff coming out, so keep an eye out for that. Don't know what it is, and then lastly, Joe's gonna talk about this subacromial spacer. Original indication was isolated, retracted, irreparable supraspinatus tears with an intact anterior and posterior force coupled. This is a balloon. This is how long it takes. It's really quick, so if you're gonna do the balloon, you have to remember that you have to have an intact subscapularis, or you have to repair it, and repairing the cuff with a balloon is an off-label indication, but for us, we actually do a complete repair and then add the balloon on top so that we can push it down and restore anterior-posterior force couples, and you might say, well, why do you do that? Well, Larry and I looked at a combined series where I did repairs of massive cuffs and he did partial repairs, and at the end of the day, the results were the same between both groups, so functionally, even though I put it all back, I am probably actually getting a partial repair. It just looks nicer when I pull the scope out, and so by pushing it down and improving the biomechanics of our force couples, we can make that better, and you have to have the coracochromial arch intact if you put a balloon in. I won't tell you how I actually know that the balloon will pop out the front of the shoulder if you do a decompression and attach the CA ligament, but I can also tell you that not exactly. If you stick it with a big needle, then it'll deflate, and that big bulge on the front of the deltoid will go away, so you kind of lose the spacer effect, but at least they don't have this big lump on the front of their shoulder. Mistake when I did it. So this is what it looks like. If you look at the left, that was preoperatively the humeral distance was measured at three millimeters. Postoperatively, we didn't change the acromion, and now look at the difference. So biomechanically, for your rotator cuff, you're given an assist, right? It's like putting a motor on your bicycle so you can go faster. It helps out a lot. Your cuff will do better because biomechanically, it's more sound. Again, do a release at the bottom. Restore your arch at the bottom of the shoulder. That's the goal of the balloon if you put it in, and Joe's gonna talk about that, and then Bassam's gonna talk about lower trapezius transfer. I think Bassam works miracles. This was wonderful thought, and he is so creative, and he came up with this himself. We do these now. When I do it with Dr. O'Brien, then we do it with two open incisions. Mike does it arthroscopically on the tops, excellent surgeon, and you use an Achilles to push it forward. This is one of Joaquin's drawings, but my latissimus dorsi's always got external rotation at the side, but I never got this, and with a lower trap, I get this overhead external rotation. So it's a fabulous operation, and credit to Bassam for that. And then reverse shoulder. Again, it's a miracle for the pseudo-paralytic shoulder. It usually functions, if you really look at it critically, at about 70% of normal, and so if you're a 75-year-old, and I'm moving along where that would be something reasonable, it's got great pain relief and good recovery. However, if you want a high functional level, if you're gonna go back and do CrossFit and do TRX and go to the gym and do all these things and you wanna do yoga, may not be your best option because the reverse is non-anatomic, and if you're younger, you're gonna get more poly wear. And this happens, and some of the most unhappy patients I see are patients that are under 50, got a reverse shoulder, and are trying to be active, and they can't do it. Or it's two years later, and it fails, and there were some very good surgeons that had a 25% failure rate at two years in reverses in folks under 50. So it's not a viable option unless that person is really sedentary and has a problem, and I do a revision reverse about every week, so it's a tough operation. Postoperatively, let's talk about this a little bit, abduction pillow, go very, very solely with these, you're not dealing with good tissue. Cryotherapy, passive motion only, love aquatics in this, and you really gotta get the scapula back because they're very protracted. Supplementation. Juven HMB is something that general surgeons that do wound healing use on every one of their patients. It's an Ensure product, I have no stock in it, but as I give you the name, because you can order it on Amazon from anywhere, mostly it tastes terrible, but we did a six-week follow-up on placing patients on it and not on it, and our cuff was about a millimeter, actually when we really looked at it, 1.2 millimeters, but I'm not good enough to really say that 2.2 millimeters makes a difference, but about 1.2 millimeters thicker at six weeks as opposed to not taking it. So I do think it makes a difference. Doxycycline is an MMP3 inhibitor. MMP3 are catabolic factors in the shoulder, they destroy your healing process, so we put people on it for at least the first three to six weeks in a revision, and three weeks in a primary massive cuff. We actually have moved to where we do it on almost, 90% of my practice is revision surgery anyway, so we put everybody on it, but on a primary, we'll put them on it for a couple of weeks. It kills C acne, so I think that's a good idea. We add the vitamin C. One in three of our massive cuff tear patients are vitamin D deficient, one in three. I mean, who doesn't think of that? So we put them on 5,000 units of vitamin D, and then we avoid NSAIDs for the first four weeks because that is a little bit of a catabolic factor. Most common complications you see if you're gonna try to do this, one, start trying to move too soon. George Murrell had a really good study that showed that people that still had a loss of motion at three months, actually at the end of the year, by MRI, 100% of those were healed, whereas his patients that had normal motion at three months had a 40% failure rate at a year. So when you're thinking about this, and your therapist is saying, I need to stretch because they're frozen, just go, yeah, take your time. Don't worry about it, it'll come back. Pendulums and using pulleys, those are active assisted exercises, not passive. So don't do those early. You can do other things. Active abduction, if you don't have your front and back force couple strength, we'll pull the repair part, and then a lot of times, what you see is people that are pseudo-paralytic. Before you start trying to do their exercises standing up, put them flat on their back and let them do this. And then we do ultrasound on all of ours. So when we looked at our large and massive tears, by ultrasound, the large ones, about 97% healed, and the massive ones, about 94% healed. Again, adding the patch and the supplements jumped that up a bit so we had better healing. So, decision making. Patient comes in the office, you got a big tear, an MRI scan. How do you know what to do? We're gonna have some great options, and when do you pull the trigger and what do you use? Well, I think eukaryotic calcification should be zero to seven and I'll explain why. Zero to four is just like he talked about. It was a CT scan study, and it was in France, and he was talking about intramuscular fat. So intramuscular fat keeps those muscles from contracting. It makes them very rigid. In the US, we primarily see where you get your views and you try to measure the thickness of the muscle, especially on an outlet view, and you say, well, it's this thick and it's shrunk down this much. Well, that functionally doesn't mean you have intramuscular fat. It just means that you have atrophy of the muscle and that muscle can recover. All right, so zero to four. Four is basically 51% fat, 49% muscle. I think you should repair those all day long. You're gonna get good results. You may have a little bit of weakness to overhead, but they should get back to normal. If they're what I would call a five, so up to 75% of the muscle is gone. It's not intramuscular fat. Then I think for those, you can repair those, but you have to tell the patient you're not gonna get overhead strength. But if they wanna play tennis, then you need to start talking about transfer or other options. If they wanna play pickleball, which is an elbow down, then you can do that, right? So you can go back to doing that. If you wanna play golf, not a problem. Unless you're really bad, your arm's not gonna be up here. It's gonna be down here so you can swing better. So those are things where you look at their activity and try to do that. This is where SCR really is beneficial because you do something to restore their biomechanics. A spacer is a good idea, especially if you have front and back force couples or you can repair those force couples. Six is 75 to 90% atrophy. Add some things if you're gonna try to do the repair because they're not gonna get function overhead. They will get pretty good pain relief if you repair them, but remember, they're not gonna get that strength. And if they have an external rotation lag, you need to do a lower trap transfer or something to improve that external rotation. And then a seven, which will be more than 90% atrophy of the muscle, you're kicking over really to a reverse if there's any arthritis because there's not much else you can do to get that back. So that's my thinking about it. I think there are lots of options for these massive tears. They're not irreparable, but you gotta figure out if they're functionally irreparable and you need to do other options. And I would always correlate patient need, the anatomy, our surgical ability, and pick the best option that's the highest ranked in all of those things. What does the patient wanna do? What are my best options as a surgeon? And then what can we do to get them back to doing what they wanna do? And I think they'll get a good outcome. Thank you very much. We'll do questions at the end.

massive rotator cuff tears

irreparable tears

tear size

tissue quality

superior migration

atrophy