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All right. So were you, we talked about the symptoms um diagnosis? Now, um, what, what, what, what would you expect to see on an x-ray? Considering that, you know, let's say the patient does not have rotator arthropathy because that's really obvious on an x-ray, but on a plain radiograph, why would you, what would you see if someone had a rotator graft tear? So basically, you would see sclerotic changes uh at the bottom of the end aspect of the acromion as well as, as the, the footprint of the tuberosity as you know, on this um radiograph. And these are signs of impeachment and most likely signs of rotator cuff disease. And if you investigate further, there would be no surprise if you see a tendon tear. So you're always gonna get the radiograph and that's the first thing you're gonna ask you, you if you're in the exam and the examiner asks you about the imaging. It will be a radiograph. I usually get, I mean, no, I usually get two views, but it's really obvious on, on the A P view, not in every patient, but, but quite a few of them with chronic uh impeachment. They have these findings on their x-rays. Yeah. Next. Um Can anyone, well, has anyone heard about the uh critical shoulder angle? So the shoulder angle is uh as seen on that uh uh picture is the angle created between a line drawn from the superior aspect of the glenoid all the way down to the inferior aspect of the glenoid on a perfect A P slash glenoid view. And then another line created from the inferior aspect of the um glenoid all the way to the lateral aspect of the acromion. So that angle, the A angle is the critical of the angle. The significance of it is that um uh depending on the size of the angle. Um people who uh who have a not no an abnormal clinical shoulder angle that might be more prone to develop either rotator cuff disease. Um uh let's say rotator arthropathy or sorry, rotator cuff tears or rot arthropathy, osteoarthritis. So, um usually uh the normal angle is around 30 30 to 35 degrees. So that's one of the things that we can measure on, on a perfect A P view. Only the golden started when you want to diagnose and basically to confirm your clinical suspicion that uh uh the the rotator cuff tendon or muscle or tendons or muscles are torn uh is with an MRI scan. Um Not every hospital has this kind of protocol in my hospital, we tend to do ultrasound scans. Uh Most of the time. And uh although they can be quite uh specific and accurate, sometimes as accurate as a, as, as an MRI scan, that depends on the user that depends on the person who actually performs the scans. So, unless you have a very good MS care radiologist who can pick up the um uh the test correctly on, on the ultrasound scan. I think the golden star still remains an MRI scan. Um My other advice would be whenever you have an MRI scan, just read it yourself before you read the report and don't rely on the report from the radiologist and uh you can see the images first before you read the report. Um and um the ultrasound scan, as I said is if you move to the next one, it might be a faster examination to do better patient experience. Patients hate that you, that they have to go into for 20 minutes or half an hour. It's definitely cheaper. But as I said, it depends on, on, on the user. It depends on the person who does it. Uh Also, I don't find it very um helpful when I want to make a preoperative planning in regards to other uh factors such as uh fat atrophy type of that, they are retraction. Um It's much, it's much more visible and better under, under understandable on uh and an MRI scan. But uh as I said, um depends on the hospital you're working in. I'm I'm not sure Karim. Where, where were you before? Uh March, what are they using there? Are they using MRI scans or uh variable? So, uh most of them would, uh at least for the acute cases, get an ultrasound scan to start with while an MRI scan would be the second point of action if the ultrasound confirms. So they will still do all of them. Sorry to pin. I just, I did the shoulder job at Norwich and when I was there, they only tended to order ultrasounds if they wanted the radiology department to inject the shoulder. At the same time, the experience that I had was that they mostly got an MRI if they actually wanted to know whether there was a tear, how much it was retracted, et cetera. Um If they'd already had an ultrasound that showed it really clearly, then OK, fine. But um generally they chose MRI if um if they weren't interested in injecting it at the same time. Um Yes, I agree. II I prefer MRI um every day of the week or an ultrasound scan. But um the way it works, we have radiologist. So um if I ask them politely, they can give me details about fat atrophy, even retraction type of tea if they can. Uh but uh if I want to plan a more complex case, I will ask for an MRI scan. But yeah, ultrasound scan is, is, is still doable in, in my hospital. So, but essentially MRI scan is the golden standard by all means. Um Yeah, so the other thing about the, the rotator cuff is that um in order to be able to communicate between us and sometimes between, between us and the patient as well, we need to have some sort of classifications in, in mind. Um I, I suppose if you, if you look around the thousands of classifications that we all hate, so I just, you know, try to give you um some bullet points about the ones that potentially you can learn and including for your exam or even for your future practice. Um So for a full thickness tear, there is the classification of the or, and co field. Um and essentially they divided the um uh the anteroposterior uh length of the in, in size, depending on, on the thickness. Uh if it's less uh on the side, sorry, on, on the length. Uh If it's less than a centimeter, it's called a small tear. If it's uh between one and three centimeters is, is a medium, uh a large tear is between three and five centimeters and a massive one is when it involves two or more tendons or the tear that involves the tendon or the tendons is more than five centimeters in size. Yeah, next slide please. Um When there is a partial thickness tear, um there is the s um uh classification which basically grades the thickness of the tear. Um in millimeters. So if you remember earlier on when we were discussing about the thickness of uh the rotator cuff, a normal rotator cuff tendon is thick around 1.2 centimeters. So based on that, it's grade one, if it's less than three millimeters in size, grade 23 be between three and six millimeters in size. And that would account for 50% or less than 50% of the thickness of, of the calf. And if it's over six millimeters, it's over 50% of uh the calf thickness. And in this scenario, most likely you will have to repair the tendon. Also, there is a classification between um uh the location of the tear, whether it's in the, in the articular surface or it, it's a bursal tear next. Um We should, we should not forget that, um, we should be able to classify the uh tendon tears intraoperatively. And the reason for that is that he will make us make a decision on how to fix the tear. Uh So based on what you're looking at once you're inside the shoulder, uh the easiest of all, and the easiest to repair is the crescent type of tear. And basically what you need to do, you need to pull as you can see on the top pictures, you need to pull the tendon all the way back to the great tuberosity. And usually these are the um uh easier ones, easiest ones to fix that next. The next type of uh tear that we need to um uh be aware of when we're in the shoulder and be able to classify and write it in our notes as well is the U uh type of tears. So these are a bit more difficult to treat um because you need, in a way you need to um make the U tear into a crescent type of tear by um passing those sutures as you can see on, on the second picture and make a margin, margin, convergence sutures. And then that leaves you with a crescent type of tear and then you, you just do the same thing as you would do for the first type of tears. Yeah. Next, the next one is um the L type uh L shape type tear, which that is even more difficult to fix. And uh the way you do it again, you, you need to pass sutures on the long limb of the tear and then bring the rest of the tendon all the way back onto the grade tuberosity as you would do for the type one crescent type of tears. That's not, that's, that's difficult to rep bear as well. Next, the most difficult ones are the massive tears as it shows here. Um And, and although it looks really nice on, on a picture on a, on a drawing, it's not as simple as once, once you get into the shoulder, you need to decide uh what part of the tear to suture first and, and what part of that sus your last. Um So you need to have very good visualization. Uh Otherwise you might end up with um a repair that will not be um uh correctly in set in the gra tuberosity and that might cause uh problems including uh repair failure. Yeah, another classification which is useful to be aware of and it's useful for you to give a prognosis to whether a thera repa would be successful or not is a good idea. Classification. Uh What basically is looking at is at the uh level of infiltration from fat tissue into the uh rotator cuff muscle. Um So there are four degrees in uh the classification. Um and, and although I think the initial classification was based on a CT scan, nowadays, we just uh looking at at the MRI scan and, and we can actually see very clearly. Uh So uh uh uh stage zero means that there's no fatty infiltration of um of the of the rotator cuff. Uh Stage one means that um there is some fat infiltration. Uh Stage two is the fat infiltration becomes more significant, but still the muscle is more than the fat. Uh Stage three, the muscle equals in quantity, the fat that is, that is infiltrating uh the tendon or the muscle. Uh in stage four, it's long gone most likely because the fat is much more than the muscle and that's a really bad prognostic sign. Yeah. Um we talked about the, the boring stuff, anatomy, um biomechanics, um and classifications. What about treatment? Um The treatment is always non operative or operative. So, um there is no blu answer to whether you need to treat someone operatively or non operatively. So you need to have both of these options in your mind. Uh And the decision making is really important because most likely that will dictate the outcome of um uh the treatment that you're gonna give to your patient. Um There are patient and factors that you need to consider and there are surgeon factors. Patient factors include va is biological aids or physical aids includes um uh comorbidities includes the um whether the patient is a smoker or whether the patient is diabetic, whether the patient is um alcoholic, whether the patient is compliant. This is a multifactorial um um based decision that you have to make when you're talking about the patient. Uh you need to consider as a surgeon, you need to consider the individual characteristics of the tear of the rotator cuff tear. Not every tear, every tear has its own personality if that makes sense. So you need to consider the uh the tear characteristics. Is it a partial tear? And if it's a partial tear, do I need to repair it? Is it a complete tear again? You need to ask yourself, do I need to repair it? Is it AAA, partial articular supraspinatus tear avulsion. Do you do, do you need to repair it? Is it a partial tear? So, you need to have all these things in mind and you need to have planned prior to the um, uh actual procedure before getting into the, um, theater. Um Also you need to differentiate between traumatic and degenerative tears. Sometimes if these two overlap each other, some patient who's over a certain age, over the age of 40 45 they might have a combination of de degeneration and, and traumatic tear at the same time. Uh Is that clear guys? Any questions so far? Right? Um, when it comes to non operative treatment, um, physiotherapy is one of uh the uh ways to treat a, a non operatively cu. Um, and it usually takes time. They don't, patients don't get better within a week or two. It takes, uh quite a long of a lot of time might take 3 to 6 months at the least. And this is something that you need to um, uh, counsel your, your patient about that. Uh It doesn't get better, uh straight away. Uh, obviously the corticosteroid injections that we use so broadly in the orthopedic uh in our daily orthopedic practice, um, we use them to address Boe uh uh me personally, I would inject um someone even with a rotator cuff tear. Uh, if I was thinking that that would help with the pain and with the rehabilitation. So I think it's not wrong to say that you still inject the rotator cuff tear uh with the steroid injection. Uh Of course, as in every uh treatment that we give the patient without an operation, we suggest in orthopedics for activity modification, which in that particular scenario would uh potentially involve avoidance of overhead activities if that's possible. Yup. Have you all done a steroid injection in the shoulder? Yeah. Can someone explain how you find your anatomical landmarks? Uh When you do a steroid injection in the shoulder? Um a sub subacromial injection, subacromial injection, you can either go laterally or posteriorly. Um That photo is well, a little, maybe a little bit superior to your posterior. Yeah. No, no, no. That's what I like. That's how I've been to do it pretty much is um just find the posterior border of the acromion, the posterolateral border. Um And or you, well, you can go about a centimeter below it or um and then basically just go up, hit the bone, come back a little bit and then go underneath it into the subacromial bursa um around about where that up or maybe just a little bit more medial than where that photo is. And then if you're going lateral, it's a very similar um can you can't see my mouse but yeah, just sort of in the midline. Um and you can just go underneath again. So it's not, it's a little bit um higher up than it would be for your posterior port where you're trying to go into the glenohumeral joint. So I, I personally would still go more or less where I would make my arthroscopic portal. Oh, fine. Ok. Fair enough. All right. I would just go there because I, I find it easier and faster to do it that way because basically it's, uh if you've done a few arthroscopies and it, it's, it's much easier to do it that way. Um And uh the way I do it as, as, as you said, I, I palpate the lateral edge of the posterior chromium. I measure probably a couple of centimeters uh inferiorly. And then with my index finger, I palpate the uh coo and then I aim up to the acromion. So I don't necessarily sort of scratch the acromion if that makes sense because I might cause patient. Uh the, the pain to the patient, you can go laterally. But um I think um I was reading some of that laterally. The uh accuracy is not as great if you do it blindly and uh laterally, I think it's basically what the ultrasound uh uh uh radiologist are doing. Actually the M sca radiologist, they just go laterally, they don't go from the back. But uh yes, it's not wrong to do it, as you said, it absolutely fine. Uh I just, just aim pretty much where I would make my posterior portal for the arthroscopy. Um Unless it's a it's a patient who is sort of, uh, has a big shoulder, then maybe I would do the same way that you described it. But generally speaking, you can always get a, um, a long enough needle to get into the sub space. But, yeah, that's absolutely fine. So, um, yeah, next, so we talked about the, um, conservative, uh, part of, uh, the treatment and, um, it's sometimes quite a few times actually works. Patients do not need any further uh procedures or they don't need an operation at all. Um What kind of metals are you aware about operating on a rotator cuff? They all here, most of them. So you either open it or, or do it arthroscopically. Um When I was starting as a fellow, I, I used to consent every patient that I was operating on for the, for the cuff repair for both of the options, arthroscopic and open. And then you realize as you do more arthroscopies, you're not feeling that comfortable, that much, comfortable to open up the shoulder even as they call it mini open um uh procedure. Um So generally speaking, a repair is reserved for uh biologically fit patients. Uh Wiz um are more than 25% the thickness, uh full thickness test after injuries, especially younger individuals around the age of 40 45 50 where they had a short dislocation and then uh they tone the tendons uh for pasta uh lesions who are more than seven millimeters in exposing the foot pain of the great tuberosity. These are a few of the indications that most likely you would jump and operate and, and repair, try to repair the tendon. Um I'm gonna touch on this um uh type of, of treatment in, in this, in this um pre on this presentation. Um But of course, you're aware of the tendon thrus um and the superior capsule reconstruction and uh the um at the end stage, when you know there's no salvage options, then there is a reverse total shoulder replacement for older people, rote prop changes. Um The tendon process they usually been utilized for, for failure of the posterosuperior calf. And does anyone know what muscles are we using usually for, for a muscle transfer, tendon transfer? Sorry, what do you know, do you know what muscle or tendon we using for to replace, let's say the action of uh the supraspinatus and infraspinatus, the trapezius. So it's usually the, the, the, the latics is doy usually. Uh And what are you using? What tendon can you use to uh replace the action of the subscapularis? Pec, I think. Yes, pec, pec major, correct. Very well. Um And um the super capsular reconstruction is reserved for massive irreparable rotator cuff tears. Um And the reverse total shoulder replacement most likely for people who have already developed er, or arthritic changes in their shoulders because of the lack of rotator cuff tendons. Yeah. Next, what are the, the principles, there are principles in everything that we do in, in, in, in surgery in general. And there are principles that apply in, in, uh, rep repairing a rotator cuff tendon which is torn. So you have to be able to see. So if you go into a shoulder and it's, it's bleeding and you can't see anything, obviously, you cannot repair and then, uh, things might get ugly because you might want to open um uh the shoulder to visualize and um then it takes more time and probably more morbidity for the patient as well. Um So first thing you need to see, you need to visualize your tendon, you need to visualize the tear. And once you do that, you are in the position to classify, to give, to give the, to give a name to the tear. Is it a crescent type tear? Is it a U shaped type of tear? It's it, it, is it a massive rotator cuff tear? Is it more than five centimeters in size? Is it retracted? How, how far is it retracted? Is it retracted all the way back to the glenoid? Because usually if that's, that's the case, if that all the way back to the glenoid, most likely uh the tear would not be that mobile, the tendon will not be that mobile. So the tear will be irreparable. So the other thing you need to do, you need to release your tendon. You need to mobilize the tendon, especially in case that um you don't do them acutely and to be honest, very rarely. Uh almost never. I would say you would do a rotator cuff tendon repair acutely. Even in the setting of um a solid dislocation that, that someone has ruptured the supraspinatus or the subscap or both, it will still be a few weeks on the line, which means everything will be scarred up. Uh So you will need to mobilize uh those tendons to bring them all the way down to the dios. Um The other thing is that if you just mobilize the tendon and you just stick it onto the bone, you won't heal. So you need to create biology. So you need to make the bone bleed and, and, and release nutrient factors that will provide the, the um uh the ma the matrix for, for the, for the tendon to heal itself from the bone. And you can do that either with um uh a soft tissue saver or a or, or a burr during the operation, the footprint, you can just slide it uh forwards and backwards until you see bleeding bone. And then this is where your, your tendon is gonna go back and sit on. Um The other thing you should be aware of when you had a tendon is the tension. Um Sometimes the tension is so great that you think you repair the tendon, but then most likely what will happen the repair will fail. Uh, and, or it will never heal on the footprint, which means it will be, uh, it will repair, even if it stays there, it will repair the, the, the, uh, sutures will pull through. Are you, are you all right with that? That anything else you'd like to ask about the principles of cuff repair? Ok. Will be done. Um, when I position the patient, I position the patient on, on, on a cell position, you can do it on the lateral to keep it this position as well. Um It's depending on how you were trained and, and what you're feeling comfortable with. Um I usually have um a Truman or arm holder, which is that device that looks like um uh on the side of the arm that holds the arm in place. Uh And then you can position the arm in pretty much in any position. Um You want to position in order to be able to see uh to have access in the shoulder um and repair the tear. Um as we said about, we said about the visualization. Um So it's really important to have an anesthetist who is um experience in giving regional blocks. I in my current place, I give sic acid. Um And um in previous hospitals, we used to give um uh adrenaline in the bags just to, to, to the just to reduce the risk of interop bleeding that would obscure your visualization. Yeah. Next and then um you have the portals. You, I always start with um a portal. Um I look in the glenohumeral joint. I recognize uh the landmarks. Usually the first thing you you can see is the locket of biceps. And then if you look at the front, you go from, from the back to the front, you can see the subscap uh and going around the shoulder, you start visualizing um the uh the bicep es uh the supraspinatus insertion, going back all the way to the infraspinatus and minor into the axillary pouch. And then you can either go from there again into the glenohumeral joint or come back the same way you went in, which is probably safer because you're risking of injuring the cartilage. If you just try to push yourself for the joint from the axillary pouch. There are many, there are many portals you can do um uh depending on where you want to uh repair the tendon from. What kind of tear that is? Is there a subscap tea as well? Do you need to do resection of the uh chro clavicular joint? Uh So uh there is no, there's no fixed number of ports that you can do when you do a um uh rotator cuff rep paras cop next. So the debate usually is when it comes to the implants, we use ankles. Nowadays we use ankles. Um And um they've come a long way. They um they really well designed nowadays and, and, and they provide with great uh pullout strength as well. Um The great debate that has always been around is do we use single row vis Taber road technique? Um uh Briefly a single road technique means means that you only have one row of uncus on the lateral side and then you have the stitches that go through the tendon as seen on the left picture, they go through the tendon, they pull the tendon down to the um tuberosity uh or a double row as seen on uh the right hand picture where basically you use two rows of ankles, one more medially, more clo closer to the joint line and the other one more laterally. Um And, and then again, the sutures go through the tendon from the medial ankles and then you just pull them through the lateral and lateral row anchors and you just bring the whole the tendon down to the tuberosity. Um A double road technique probably provides better healing to the tendon because it just puts the tendon flash onto the credit tuberosity. So that potentially provides better healing opportunity to the tendon onto the bone. And it is bio biomechanically superior and it's more resistant to um uh el rotation. A double road technique obviously in practice and I personally do the same thing depending on the size. I will either do a double row or a single row if the tea is small and cannot fit a double row, um uh construct of uncus, I would go for a single row and um and, and usually just works as fine as uh a double in a way you right? Can you hear me? Yeah. Yeah. Ok. So um the single row, it's um it's better, better to have a, a AAA nicely executed single row, uh ankle technique rather than over tension, double row because that will lead to failure at the muscular 10 tendinous ju of the 10 of, of, of your calf. So at the end of the day is how well technically you fix a tendon most of the times in these situations. And obviously, it depends on, on uh the type of the tear and the size of the tear. You can at the same time enhance the biology of your repair. There are techniques nowadays, if you can, you change, can you put the next one? Yeah. Um You can either do micro fractures as you would do in the knee you can do in the tuberosity um or you can augment it with um uh you can augment your tendon repair and this, all these things are are newer things coming out now. And basically, there's no data suggesting that one thing is superior to the other. So um uh a thing, the thing you need to remember is whenever you uh fix the tendon back on the tuberosity, make sure that it, it's not too tension that it's not gonna strangulate that your repair is not going to strangulate your, your tendon repair. Right? Um Yeah. Next. So, um I just, I'm just gonna just briefly describe um what Bo Bo had and, and, and lo um said a few years back 2010, I want to say um about the um rotator cable uh around the shoulder. This was a cata study and the reason I'm just bringing it up is may, maybe that will give us a, a bit of um insight on which stairs do well without an operation, which stars do not do well. So um the rotator cable is a tissue that runs from the back to the front, from the back, all from the super, from the back of the supra, all the way up to the uh uh superior border of the uh subscap. And if you show on the lefthand picture, um the rotator cable is that thick tissue that is just on the edge of the um of the humeral head and, and, and goes around all the way in the front and then on the right hand side, um the trying the the trend actually to, to give you the insight of how it looks and how it look if that was a breed. So if this breeds which in this uh particular case, the uh anterior and postma aesthetically, the subscap and the infra, they're holding the node, the node collapsing. That means that even if you have a small tear on the te the spins, most likely that will not affect the function of the shoulder, the shoulder will continue functioning. And probably that might be an explanation why some people with tears are not in pain. And it's just an incidental finding that, you know, they might have on the scan and they still functioning absolutely fine even in, with a tear in the shoulders. Um, and that's not something that you need to know for your exam, I suppose. But um unless you um you're aiming for, for um uh uh high points, otherwise, uh it's just just a consideration of how these biomechanics work uh in relation to a shoulder tear. Is that clear? Yeah. Yeah. Um I mean, talking about complications, um there are complications as in every kind of operation we do in, in, in uh theaters. Um There is a tear rate um and that happens usually uh when uh there is failure of the tissue to heal onto the bone. Um and that might depend on patient factors or, or, or technique factors as well. Um Depends on the patient compliance at the same time. Uh Having said that there are physiotherapy protocols. There are two schools in that there are protocols that they uh advocated more aggressive rehabilitation after a, a repair of the tendon uh with uh uh early active uh uh movement versus the other school that dictates uh advocates a more delayed kind of uh active range of movement. Um, I'm somewhere in the middle of me personally. So, depending on, on, on, on the type of the, of the tear, depending of the, of the tendon, depending on the patient compliance. Um, I might go with one or the other. Um, if, uh, I'm happy with the repair, especially a double road repair, which is biomechanically stable, I might be more aggressive with rehabilitation. But again, uh, I think in the literature, um there is no difference and there are no higher rates of uh retear if you uh actively early mobilize a patient after a rotator cuff repair. Um in many open procedures that you have to detach the deltoid and you don't reattach it. There is a risk that it might stay detached and that cause problems and even in stability to the shoulder. Uh there is the risk of a nerve injury, um including the uh suprascapular nerve, especially when you try to mobilize um intraoperative with the supraspinatus and, and, and it's really scarred up and you're still trying to pull it with all. You got all the way down to the g to sometimes uh there is traction injury to the uh suprascapular nerve. Um for people who are using the position there is I've never seen it but, but it is described in the literature, um a lateral femoral cutaneous nerve injury, uh by the way, you're strapping, uh the patient around the table, uh like in the infection is not, it's not a high prevalence of infection is less than 1%. Uh There is the risk of stiffness. Um And this is something that I always counsel my patients uh about uh that they will be stiff for a few months. And also I'm telling them that to go back to uh what they were doing before it might take all the way up to a year. Uh pneumothorax, it can be uh iatrogenic either by us during the arthroscopy uh or by the Anestis during uh the regional block. Um But again, it's, it's, it's a very rare complication. Um and pretty much reaching to the point that um uh finishing the presentation overall, the key successful treatment is to make the right decision. And it might sound like ELISA because basically, that's what makes um a good surgeon and a good doctor is to make sure that the decision is the right one to make for the individual that he or she is treating. Um So you need to recognize the right candidates at an early stage. The reason for that is that the sooner you recognize them, the sooner you can offer them uh the right treatment. So most likely the outcomes will be superior rather than having a late recognition of those right candidates. Um There's nothing to replace a correct clinical examination of the rotator cuff, but definitely you would get an MRI scan on top of or an ultrasound scan. Inside the se centers uh on top of a, a simple x-ray that will help you um uh keep the prognosis and that will help you to your patient about the uh success rate of a tendon repair. Um Last but not least we should respect the biology and the biomechanics. So um that will include the type of the anchor, probably single, double row insertion of the ankle. There is a certain angle which is called the dead man's ale the way you're putting the anchor into the bone, which shows that it has uh uh superior results in terms of pullout strength. Uh The newer anchor that also suture anchors uh for Roff repair, um which um they cause less uh less formation of cysts in the humeral head. And uh they are small in size, which means that potentially if you ever need to revise, it would be easier for you to revise. Um And the type of sutures usually I use, I think most of the surgeons, the epilepsy are using fiber tapes because they are broader, broader in, in, in um in size, they're not, they're not thin. So, uh and that helps put the tendon very nicely down onto the footprint. Um The downside of that is that you need to have the correct tension because if it's too much tension, you might still strangulate the um uh the tendon and the repair might fail. Um And that's all for me. I hope I hope I didn't put you to sleep. Any questions, any questions regarding techniques regarding treatment? It's a controversial, controversial subject. The rotator cuff in terms of how and how you operate on it or how you don't operate on it. Yes. Go and carry him. Yeah. You want to buy something about the dead man's angle. Um Yes, it's more, it's mo it's basically more than 45 degrees. Sorry? OK. Uh No, I think, I think the, like I, I kind of w what was the question can you ask me again? Now, I was asking, what is the men's angle? Dead mass angle is, is when, when you put the, um when you pull the anchor into the bone, it has to be on a certain angle to uh ensure that there will be no pullout of the anchor to have the be the better possible grip of, of the bone when you put it in. So dead man's angle, it is 45 degrees in relation to the surface of the footprint. So that's, that's the, that's the, the, the, the angle, the technique that you're using to insert the, the anchor into the bone into the credit tuberosity. And that's supposed to just put into the greater chasity. Yes. So, so you, you don't put it transversely, it will, it will pull through uh if you do a double row still in the lateral row of the ankles, when you go more to the lateral side you will still put it on that in, in relation to the surface of the lateral aspect of the foot pain. You will still put it in, in that same angle if that makes sense. Yes. Yeah, that does make sense. Thank you. It's a controversial, as I was saying, it's a controversial subject, the rotator cuff. And even if you go to your exam, you still, you still have to offer um both options uh, conservative versus, versus surgical treatment. In clinical practice, this might change a little bit. But, but when you go to your exam, you always have to offer either or it's, it's a, you know, in a way, it's not like a neck of femur fracture. It's not like a neck of femur. You operate, it's, it's a rotator cuff. It's different. There is a, there's um, um, a whole list of things that you need to consider before you decide what to do. And, and as all things in, in orthopedics and in surgery and in medicine in general is all about decision making. And we, we, we try to the extent that we can to get the right decision because their own decision will cause problems to, to, to the patient, first of all, even to yourself. But, um, uh I said it's a controversial kind of subject in um, in upper limb still. And we don't have all the answers and in terms of uh the morphology of the, and its effect on the causing rotator cuff tears. Is there anything that can be done to reduce the risk of retear for those patients who have uh uh you know, the uh are you, are you talking about a cros uh you can do acromioplasty? If, if let's say it's a type three acromion as uh classification, you can do an acromioplasty flatten the inferior surface of the acromion and create um space between the tendon, your repair and the bone. At the same time, when you s when you scrap a little bit of bone off, you release, you make the bone bleed, which as we said, it, it, it, it creates biology for, for the tear to heal. Um There is no, you cut off sort of a standard. I I couldn't hear you. You cut off. Can you ask me again? So, is that something that is done? Uh usually as a standard with, it's not done as a standard. If you look at the literature again, uh there is no evidence that doing an acromioplasty is, is superior than not doing one. I personally don't do acromioplasty. I would do acromioplasty if it's uh if I'm repairing a, a rotator cuff tear, probably on an elderly patient that has his, his or her uh human or he has a tendency to escape proximally. And I think I'm still trying to save the patient from having a va the replacement, then I might just save the acromion just to create more space, but generally speaking, you don't, it's the, it's not, there's no, there's no consensus that you have to go and do an AROS. I don't do a Chromos. I used to do. Uh um, but there is no, there is no uh evidence suggesting that doing an echo myopathy, you have superior results to not doing one. And don't forget that acromioplasty is, is involving sort of in a way chopping off bone that causes pain and patients take time to recover from that. So I, I see that as well. So you, you find it quite, you find it quite painful. Someone saves your acromion, it's painful. So it's more painful than the actual, the rest of the operation. So I can't see any clinical, um, uh, reason to do acromioplasty unless I have to because sometimes you are in the shoulder and it's really tight. Yes, it is really tight in that scenario. Yes, I'll try to create more space for me to do my repair. Uh, but it's not my general rule that we will always do acromioplasty. Yeah. Thank you very much. Anything else guys, ho ho how many of you have done a jobs? Look you've done, right. Uh Yeah, I just finished it. Who do you work with Alex? Um, yeah, I ended up being the only shoulder there in the end. Um, the other one went off on fellowship. So I was kind of working for all three of them. In the end. I know Alex. I don't know the rest of them but I know Alex Emet Griffiths and I, I know Alex. Yeah. Um, yeah, it's, um, slightly different from, from, you know, from the rest of the rotations that you need to do, uh, the upper limb. But it's equally nice. Maybe nicer, totally unbiased opinion. No. No, I always say that. Um, it, it's good fun. It's very good fun. Yeah, it is. It is fun. It is fun. No, it's fun. I mean, it's at the end of the day, it's your decision. What uh you know, you think it's, it's better. But uh Karim will tell you when he finishes his rotation. It was a that, you know, he's been his best rotation like he's had, it's already great. I said you, you tell them once you finish your rotation in West south and upper limb that it was the best rotation you could do. Yeah, I, I'm sure I will, I'm sure. Anyway, um anything else guys, anything else you would like to ask? Um If that's the case. Um Thank you for having me today. Sorry about um this technical difficulties. I it was the first time I was using this platform. Um Ka thanks for the help. Absolutely. I think everybody uh even people that use it usually tend to have technical difficulties. It's uh sort of built in. Sorry, sorry, the technical difficulties seem to be built in with this platform. So even the people that use it. Yeah, it's um it's fine. It's just um so I, I was expecting that, but I wasn't expecting that I wouldn't be able to upload to a sort of like share my screen. But anyway, that, that was we overcame that that obstacle was fine. Um As there's nothing else, uh Thank you for uh for being here. You don't have any other questions. Anyone has anything popping in his mind in his mind right now can ask me. Um uh All right. So, uh hopefully I'll see most of you, Karim. I'll see you soon. Uh Hopefully see I meet the, the rest of you soon as well. Um I wish you a good rest of the day and uh, yeah, if you need anything, any questions, any help whatsoever. Um I'm available. All right guys. Take care. Bye bye bye. Cheers. Thank you. Bye bye bye.