I'm just gonna briefly touch on Superior Capsule Reconstruction and then we'll have a few minutes for questions at the very end. So we have, again, at this meeting, spoken a lot about Superior Capsule Reconstruction. Just to review, Dr. Mihata originally published his biomechanical findings in AJSM 2012. The idea being to reconstruct the Superior Capsule, prevent superior migration of the humerus. He has been using fasciae latae autograft, attaching it to the glenoid superiorly medially and the greater tuberosity laterally, suturing any residual rotator cuff to the graft with the idea being to optimize a forced couple for elevation of the arm. Biomechanically, he did find that superior humeral translation was restored fully after Superior Capsule Reconstruction. This was his original publication on his clinical results. He found excellent initial clinical results in 24 shoulders, improvement of active elevation, external rotation and ASES scores. Patrick Denard and Steve Burkhart published in 2018 their outcomes. Again, they found good improvement in outcome scores as well as forward elevation and external rotation. They deemed that approximately 75% were successful and they found a significantly greater prevalence of pre-op subscapularis atrophy in the non-healed group. So this may be a predictor for failure of SCR. Mihata's five-year results were published in 2019, 30 patients, 90% graft healing, improvement in outcome scores both at one year and still some improvement up to the five-year time point. No progression of cuff arthropathy in patients who had healing of the graft, but severe cuff tear arthropathy in all patients who had torn their graft. Burkhart published his further minimum two-year outcomes findings and found that 85% of his grafts healed, but there was a 19% rate of unsatisfactory outcomes with revisions and 14% failing to reach the minimally clinical important improvement in the ASES scores. Most recently, we found some findings out of the RUSH group where 54 patients, minimum one year follow-up, 20% clinical failure rate, higher failure rate in females and in those with subscapularis tears, and they found not statistically significant finding, but a trend towards higher failure in patients with an elevated BMI, lower preoperative forward flexion, and lower preoperative acromiohumeral interval. Labelle and Gillespie also published last year, 35 shoulders, improvement in all outcome scores, however, a high failure rate of 62% by MRI. Interestingly, graft healing did not affect the outcome scores, so they postulated that clinical improvement may be secondary to a partial repair, debridement, and or biceps management in these cases. So the key principles of superior capsule reconstruction are really to select a patient with a lower HAMADA grade, HAMADA 1 or 2. You wanna fix the graft at 15 to 45 degrees of abduction. You wanna do a very careful side-to-side repair of the remaining intact rotator cuffs, the tendons that are present. It's very important to have an intact or repairable subscapularis, and we know that it's better to have higher graft thickness, particularly three millimeters and higher. Like Dr. Savoie mentioned, folks are even using up to eight to 10 millimeter thick grafts. Yeah, obviously, it's not indicated in patients who have significant anterior superior escape. I'll defer on this case. This is just a case presentation of a patient treated with SCR. This is a technique video, a cursory of Dr. Gamrat, demonstrating some of the steps. My technique is such that I use three anchors on the glenoid, and then I bring it over to a transosseous equivalent repair on the greater tuberosity. So these are just some steps demonstrating this technique. This is an example of someone at 2 1⁄2 year follow-up. On the left side, she has an SCR. On the right, she has a reverse, so good forward elevation and good external rotation. She's happy with this particular procedure, joint preserving. So in conclusion, massive and irreparable rotator cuff tears remain a challenging problem. Multiple treatment options exist. It's important to have a very, very good understanding of your patient with a detailed history, physical exam, and a review of their imaging, as well as a very thorough discussion of the goals, risks, and benefits, as well as their expectations. These patients oftentimes are the most complex discussions that I have of any of my patients. It's important to have a very good, thorough, shared decision-making process with these patients. Thank you so much for your attention. And I'd like to invite Dr. Savoie up to the stage. So I'd like to open up to any questions from the audience. I would like to ask Dr. Savoie about that. We are now a little bit confused about the fat infiltration and the atrophy. So you just mentioned Goutelier, and it's like a seven grades, and we know that it's like a four grades. Then you mentioned this atrophy and infiltration. So can you a little bit explain this? And what's your cutoff point that when you are thinking about do something in the cuff, if it's like too much or high-grade infiltration or fat atrophy? It's actually two different things. So the infiltration is when really the bulk of the muscle is essentially normal. So the muscle, it may be shrunk down a little bit, but the fat is all within the muscle. So the overall circle, if you would, on your tangential X-ray is about the same. It's not shrunk down. Now, every MRI that we saw from Joe, from Basim, from Peter, and the ones I showed you, the cuff muscle is shrunk down and small, but once you take that circle, there was no real fat inside the circle. So that is atrophy, but not necessarily the fatty atrophy that is such a bad sign. So if you have intramuscular fat, it prevents muscle contraction, and the muscle, not only is it not flexible, even if you slide it over and put it on top of the tendon, it's not gonna contract. As opposed to every MRI you saw where the muscle bulk is smaller, but the muscle that's residual is functional. And so then what you do, if you do nothing else and you don't get hypertrophy, then that muscle will function. So if you have 75% of the muscle gone, and in your normal state with your non-operative arm, you can lift 20 pounds overhead, and you lose 3 4ths of that muscle, then on the right arm, if you fix it, they'll be able to lift five pounds overhead, but that's it. And so the question is, is that strength, the residual muscle will provide enough strength, if that function is enough for you, then that's good. If your goal is to lift 100 pounds overhead, and you have only the ability to lift five, you're gonna be unhappy with me as your surgeon, because you can't lift that 100. And there's nothing I can do, maybe stem cells is the future, maybe anabolic steroids after a year. So there may be other experimental options that will come around, but we're not gonna gain that strength back in its current state. As opposed to one that has pure fatty infiltration, if you put it back there, you're essentially putting a graft on top of the shoulder to hold it down, it's not gonna function. So your overhead strength will not exist. So this is what we knew before, that when you have a high grade fatty infiltration, we're not talking about the atrophy, so this is irreparable cough terror. So when you have like a grade four, you will not find the tandem, because we know that's when you have a higher degree of fatty infiltration. I disagree, we can talk about this offline, but I would disagree vehemently with the fact that if you tell me you have a grade four, that there's no tendon present and it's not fixable, that's simply not true. It's simply not true. You can send your patient to me with that and I will fix him every time and I will get 96% of them back. So that's not true. And that original concept with Goutelier that it's now irreparable and that's ingrained, Pascal was very adamant about that, and you could show him an MRI and say, is this grade four atrophy? And he would say, yes. And then you can show him a video of the patient moving the arm in a normal position with excellent strength and he would just say, well, that's not possible. And you go, it's a video, I'm showing you the patient, he's moving the arm and he would say, I don't care, it's not possible, you made a mistake. Well, if I made a mistake, I made a mistake by fixing the shoulder and making it functional, right? That's not a mistake, that's just, nothing's a rigid concept. So you have to decide when you look at it, can you fix it? And is it truly not gonna function when you fix it? Those are two different things. Yeah, one more question, please. Is there any data show that if you do a partial repair alone and compare the function with a partial repair with any kind of augmentation like a SCR or patches or anything, is there a comparable data that when you do just a repair or regain the force coupling, then you have a very good function compared with any kind of augmentation with a partial repair? So the data is separate papers. The best thing to look at is Burkhardt's old paper on partial repair and compare it to his newer paper on SCR. Because if you look at the functional data between those two studies, they're exactly the same. And then for us, our paper, we won the Herodicus Award for that, we had an 85% success rate with massive irreparable tears without the patch and a 96% success rate with the patch, same technique, but it's small numbers. You know, orthopedic evidence is very fragile. If you really wanna know, we need a huge multicenter level one study where everybody's randomizing it to repair plus augmentation or repair what you can, a partial repair. And that's why I alluded to Larry and I studied because I fixed every one of those and he just did a partial repair and the results were identical. So no different. Dr. Savoie, I completely agree with what you said about the fatty degeneration. I do a lot of them. In my hands, I think if you are able to restore some of the biology and protect your repair for two months, you'll probably do well. But my question is sometimes I find difficulty with if you have a short tendon length. I think this is a very important factor. So I wanted to know what you think about it. So I medialize, I will medialize the footprint about up to eight millimeters. I can do it a centimeter, but at a centimeter, you're gonna start to lose some abduction function. But you can go eight millimeters and with a short tendon and put it right there on the medial side. Do not try to stretch it over the side, but you repair it right there off the articular cartilage, which is medialized. That's where the tendon would normally sit. And that's what I do. I repair them more medially and don't even try to do anything laterally. I'll microfracture laterally, but there's nothing else. What kind of sutures do you pass? Because some of the sutures will cut through the tendon. So for those, I will do a convergent stitch, more like a ripstop stitch, very short tendon. So I'll do that kind of at the muscle tendon junction and my stitches go through obliquely so that I have extra holding power so they come down. So the ripstop is far enough lateral that it's not gonna affect my medial blood supply. It's very technical. That's a really good question. Thanks a lot. Thank you. Two questions. One, with the balloon spacer, why isn't it made out of something more durable like silicone? So silicone will destroy the joint. It's like making it out of polyethylene. It has to go away. Otherwise, it's just gonna erode the humeral surface. So it's just erode because it's too small. Yeah, so you can't make it any longer than you have it. I'm amazed that the result lasts as long as it does. But you're just trying to change the soft tissue dynamics about the shoulder. Okay. Other question. I saw that you repaired a rotator cuff and then you put the spacer on top to keep it depressed and allow for rehab. Are you concerned, and you made a big point of this, about circulation from the pressure? I am, actually. And we're gonna look at these results. And Laurel and Foss was doing that for a bit. And then when we finally got the balloon, we're trying to figure out where it goes. And for me, an isolated balloon with nothing else is a very small indication. I think I've done one since it got approved in this country for that indication and someone that really met all the criteria. So just doing it by itself, you have to have an intact subscap. You need to have an intact lower infraspinatus. You can have the supra and some of the upper infraspinatus. But that's the only indication and someone that's not as physically active, perhaps. But doing it on top of the spacer, we use a smaller balloon and the shoulder moves when the balloon is in place, so we move them. But I don't know, it would be another year before we know the data on whether that is actually effective or maybe it's detrimental. Don't know the answer to that yet. All right, thank you. Any other questions? Thank you all for your time and joining us. Have a wonderful rest of your meeting.

Superior Capsule Reconstruction

rotator cuff tears

biomechanical findings

patient outcomes

shared decision-making