0:00

So the history, this is 61-year-old with, uh,

0:06

a history of a rotator cuff repair

0:08

and now has, uh, pain in the left shoulder.

0:10

I'll do this one rather quickly.

0:13

So this is a postoperative case

0:14

and Don didn't have enough time

0:17

to really hit the postoperative scenario,

0:19

and maybe we'll do that when we do part two

0:22

or come to visit you all.

0:24

So here is a patient that has fluid in the, uh,

0:28

subacromial subdeltoid space,

0:30

and we'll talk about throughout this course how we use fluid

0:33

to gerrymander our thoughts and feelings about a case

0:37

and a finding, how relevant it is or not.

0:40

But as you come over, uh, to the repaired cuff, uh,

0:44

there are a few things that I do in a repair.

0:46

I look inside the repair

0:48

to look at the internal architecture.

0:50

I look for vocality.

0:51

The other thing I do is I look at the volume of the repair.

0:54

You know, I know what the volume should be as I've seen

0:57

so many of these, but also I look medial, I look lateral.

1:01

And when you look at this one, you see a bit of attenuation.

1:04

It's like a little bit of sor right here.

1:07

And right above that area of sor

1:09

there's this little round object right there

1:13

that doesn't belong or connect with anything.

1:15

It's floating. And as you keep looking,

1:18

you find another object that's a little more round.

1:22

This is a proven case, uh, where time constraints.

1:26

So I'll tell you the answer right away.

1:27

This is a, the tip of a bioresorbable anchor,

1:30

and most likely

1:31

what happened is this anchor was a little bit proud.

1:35

The tip broke off and floated into the subacromial space.

1:41

And this proven is a bit of suture material

1:43

that also floated out with it.

1:45

So this is an abnormal, uh, rotator cuff repair

1:49

with some foreign bodies

1:50

that are sitting now in the bursal space.

1:53

Any comments on this one, Ben?

1:55

Yeah, just a quick comment.

1:57

I always wonder if it would be wise

2:00

to do postoperative imaging to get a baseline.

2:04

Uh, and the reason I say that is a lot

2:06

of times when they repair 'em, they're able

2:07

to reattach the bursal sided fibers.

2:10

They can't reattach articular side,

2:12

they come back with shoulder pain.

2:14

You see the retracted articular side

2:17

and you're not sure if it's a retear

2:20

or part of the original tear that they couldn't address.

2:23

So I, I wondered whether we would do better.

2:26

I know we're not gonna do this,

2:28

but I, I think it would be very useful if we had initial

2:32

baseline post-op, uh,

2:34

at some point following the initial surgery.

2:36

I mean, I'm a big fan of that thought for, for a number

2:39

of reasons, and we both know that, uh,

2:42

the repairs are not competent, so if you inject them,

2:44

you're gonna get some extravasation.

2:45

So that doesn't help you that much.

2:47

So if you had an immediate postoperative, uh, study, a lot

2:51

of these complex signals

2:53

that occur in the postoperative state, fibrosis,

2:56

leading suture material, et cetera, uh,

2:59

you could probably sort out if you had

3:01

That baseline. Yeah, it would help. It

3:02

would certainly help.

3:03

Okay. We're gonna take some questions,

3:06

I guess, from the audio.

3:09

So I guess, uh, we can both, uh, you know, discuss this.

3:12

So this is in a, I think it's superspinatus

3:15

or sub, I'm not sure what SSP, what would you say?

3:19

Supraspinatus. Supraspinatus, Yeah. Deamination tear.

3:22

Does delamination seen as different amount

3:25

of traction indicate we are dealing with a chronic tear?

3:27

No, I don't think so. I've seen that following an injury

3:31

that I immediately, you'll see that there is a,

3:35

a full thickness tear,

3:36

but the degree of retraction is not the same.

3:39

And as I said, I only maybe once

3:41

or twice have I seen the bursal sided fibers retracted more

3:45

than the articular side.

3:47

Or may acute tears also show delamination.

3:50

Yeah, so I kind of answered that.

3:52

Uh, so I don't think it's a sign has

3:55

to be chronic in nature. I don't know.

3:57

No, I, I completely agree.

3:58

Take taking that even a step further.

4:00

I don't know if my panel work,

4:03

but when you have these, see there we go.

4:06

When you have these interstitial deamination tears,

4:08

which may be collagen sparing,

4:10

eventually these micro fibrils will, will be affected.

4:14

And sometimes you look inside

4:16

and you'll even see the microfibers bend on themselves.

4:19

So when you're looking at these interstitial tears at the,

4:22

these delamination tears, you have

4:24

to look inside the window.

4:26

Don't just look at the, the tendon itself from the outside.

4:28

Look at the interstitial and examine it carefully.

4:31

Okay. Another, uh, can CPPD calcifications also migrate?

4:36

Or is this limited or typical for hat only?

4:39

So we studied CPPD. It's one of my favorite, uh, diseases.

4:43

And calcification is fairly common if you search for it.

4:47

And we saw it most commonly in the supraspinatus in the, uh,

4:51

achilles, in the, uh, triceps.

4:53

Those were the three of the common sites,

4:55

but also quadriceps, patella tendons.

4:57

And we did not see any cases of migration,

5:02

although in certain cases we didn't get follow-up imaging.

5:05

So in the cases we did have follow-up imaging,

5:08

I never saw migration of those, uh, calcifications.

5:11

And they are distinctive. You can tell them apart.

5:15

Um, let's, let's see.

5:18

Do you, uh, routinely report a chromium type? Do

5:23

Do we re routinely report a chromium type?

5:26

And I'm assuming that you are referring to the,

5:28

the question asker, the big liani grading system.

5:31

I try and stay away from names and EPIs

5:35

or if I do, you know, I'm in private practice

5:38

and if I do use an epi, one

5:40

of the worst things you can do is make

5:42

your clinician feel stupid.

5:43

You know, they're calling you up on the phone

5:45

and asking you, you know, what does this mean?

5:47

Oh, so if you're going to use an epon,

5:50

define it in parentheses in your report.

5:52

So the answer is I don't describe,

5:54

I don't use the bani classification system.

5:57

I'll simply describe what I see

5:59

And I would answer that.

6:00

Uh, all though in my next lecture, I'm gonna tell you not

6:03

to use Roman numerals.

6:05

We do include in fact the acromial type.

6:08

Uh, I don't know, it's just something I've gotten used to.

6:10

But I always add in the sagittal plane

6:13

because there is typing that occurs in other planes as well.

6:17

But, uh, uh, that's one

6:20

of the few times I use classification.

6:22

I eyeball most things. I don't measure them.

6:25

Me too. Yeah. And you can get down

6:27

sloping in the corona protection.

6:28

Yeah, you showed a case. So it was good.

6:30

Uh, rim rant is interesting.

6:35

That is a term that is used for an articular sided tear

6:39

of the distal supraspinatus tendon, often with erosion

6:42

of bone, small cystic change.

6:45

And I could tell you, if you look up,

6:46

the pasta definition is almost identical.

6:49

So I can't tell a pasta from a rim rant

6:53

and never have I mentioned that in the last five years.

6:56

I've not used those terms at all.

6:58

I describe, as I said, what part of the tendons involved.

7:01

Is there bone involvement?

7:03

Is it going likely concealed

7:04

or non-con concealed at the time of surgery? I don't know.

7:09

I have, I've gone to descriptors as well.

7:10

I used to use the term rim rent a lot, um,

7:14

until my orthopedic colleagues, uh, let me know

7:16

that in the orthopedic community,

7:18

that term has fallen into

7:19

disfavor. So I've stopped using it.

7:21

I think there's only six arthroscopists

7:23

who introduced all those terms.

7:26

They're popular.