Welcome back, everybody. Good to see you all tonight. We had a wonderful first evening yesterday. Latul did a fabulous job moderating, and Volker will do so tomorrow. It's my job tonight. I can't say how much I've enjoyed it thus far. We've got another stacked lineup tonight with some fabulous presenters. We're going to begin with Rachel Frank, who's now an associate professor. Congratulations on the promotion. At the University of Colorado, she was a former Rush resident and fellow, so she's near and dear to us here in Chicago. She's going to tell you what it's like to be a good fellow and what steps you have to take to get there. It's going to be a power-packed event. It's going to culminate ultimately with Dr. Dugas and Dr. Verma doing live demonstrations. We're going to see an All-Amer Colorado reconstruction and a Latter-day. These are cases which you're going to hopefully do in the course of your fellowship. They are sort of the higher-end procedures, so pay attention, take notes. It's going to serve you well. Any other updates from Latul or Volker, would you like to chime in? All good. Yeah, there will be evaluations afterwards. Just remember to kind of take mental notes, and evaluations are important, so keep those in mind and keep the questions coming. A lot of great questions last night. We will have the opportunity to review questions at two points. Following Dr. Frank's presentation, we'll have five minutes, so please send those questions along. I will compile them and do my best to convey them. Following the next three or four presentations, we'll have another 30-35-minute discussion. So I think the more engaged all of you are, the more we're all going to get out of it. There's no silly questions. If you're thinking about it, somebody else is as well, so please participate. It's going to make it that much more meaningful for all of us. Remember, if you're tweeting, shout out to AOSSM fellows. If you're free to post anything you see here on social media, I think we can build some momentum and awareness of what we're doing. Educationally, it's for the best. You can follow us on Twitter, Instagram, LinkedIn. Here's a quick link as far as how you submit questions. It's pretty straightforward. I'm sure everybody's accustomed to these live broadcast events by now. So without further ado, shall we start with Dr. Frank? Okay, well, thank you very much, Dr. Forsythe, for that introduction. And to the other course directors and Dr. Forsythe, thank you for having me. It was great to be here last year. And obviously we'd all like to be in person in Rosemont, but this virtual meeting put up by the AOSSM is just incredible. I'm very grateful to the AOSSM for having me here as well. And for the fellows, just welcome. You're joining the sports medicine family and look forward to meeting the new fellows starting at the University of Colorado, but also looking forward to meeting all of the rest of you, hopefully at some upcoming meetings when we can finally be in person. So I was asked to talk about keys to success as a fellow, and I think what I'll present here is just my take, mixed with a little bit of advice from some of my mentors, some of my colleagues and some of the fellows that I've had the lucky opportunity to train over the last couple of years. And I'm happy to answer any questions either now or via email, text, anytime, open book, and you're welcome to contact me. My disclosures are not relevant to this talk or this course, but they're available online. So first to all of you fellows, congratulations. I'm sure this is what your residency graduations look like, not what you expected. You put in five or more years and had to graduate either virtually or in small groups, but, you know, take it from myself and all of your future faculty. We really applaud you for what you've done for those five years. And now you're off to the best year. So fellowship is by far the best year of your academic training. I absolutely would go back and do it again if it paid a little bit more, but it's a phenomenal year. These are my four co-fellows and myself at this course when I was a fellow a few years ago. And hopefully, again, we'll be able to do this in person in the future. These are four of my best friends. And for those of you in programs with more than one fellow, which is virtually all of them or most of them, you're going to make lifelong friends and colleagues. So the keys to success, if you just watch this 25-second video clip, you'll learn everything you need to know. We will be perfect in every aspect of the game. You drop a pass, you run a mile. You miss a blocking assignment, you run a mile. You fumble a football and I will break my foot off in your John Brown Hind pass. And then you will run a mile. Perfection. So that's what we want in fellowship. We just want you guys to be perfect at all times. So these are the keys to success. Be perfect in the OR. Make no mistakes ever. Make sure you write all the notes in clinic, even for patients that you haven't seen. Make sure you cover every single game for every college, high school and professional team that's affiliated with your program. Make sure you're pleased to be everywhere at all times and know the preferences of every attending on day one. If you can accomplish all of that, and I think this slide works a lot better in person so I can see everyone's face, but I'm assuming you're all laughing at this. But if you can accomplish all that, you'll have a great year. And we're just kidding. So that's not what it takes. So let's talk about some don'ts. And some of this is obvious, but some of it is less obvious. So keys to success are some don'ts, and then we'll get into what you should do. So first of all, complaining. We all know about that. We don't like to hear complaints. You don't like to hear complaints. No one really likes this. So try not to be that person who's complaining about how much you have to do or how much coverage or if you take call, what the call was like, et cetera. You know, this is one year that you're choosing to do, and we appreciate that as your faculty. But we also want to make the most of your time there. Vacation. So this kind of got some eye rolls last year. Obviously things come up and you're allowed to take vacation. That's part of the ACGME rules and whatnot. But remember, this is one year to soak everything up. And I think particularly now when we have to deal with situations like COVID where you may be forced to take a prolonged vacation from the OR due to restrictions at your hospital or surgery center, any other time that you're taking voluntarily may really detract from your fellowship experience. Try not to compare attending. So you might come from a program where your attendings are superstars in sports medicine, and then you come into your fellowship and say, well, that's not the way so-and-so did it. That's not really what your faculty want to hear. Your faculty may ask you, hey, how did so-and-so do this? But you want to be careful not to compare attendings from your residency to your fellowship, and you want to be careful not to compare attendings at least out loud when you're in your fellowship from one rotation to another. That's one quick way to give yourself a reputation that you might want to take back. Just keep your thoughts to yourself and take notes and certainly remember how different attendings do things differently. But not at the beginning of fellowship do you want to really advertise that maybe another way is better. You're there to learn, but your attendings will ask how so-and-so did it. I get asked that all the time, you know, how did Forsythe do this or how did Verma do this? And, you know, I get asked that. When I even joined as faculty, some of my colleagues would ask me that, and certainly that's okay, but it's volunteering that information that can come off in the wrong, just leave the wrong taste. You want to not be late or leave early. We've had some of these instances and we've all, you know, have things to do. We have schedules to keep. We have significant others or commitments or kids or whatever, but you don't just want to check out. Always check in with your attending and make sure if you need to be somewhere or you have to be late or you're taking a job interview or something like that, just keep the communication channels open. You don't just want to not show up. And while that sounds common sense, it does happen. Careful making excuses or being unavailable. Again, this is one year, and you may not be covering the university basketball team, but one of your co-fellows may have an emergency or something come up and may ask you to cover that. Try to be available. You never know when you're going to need your co-fellow to be available. Your attending may need you to cover a high school football game that you're not covering, and you may need to cancel your Friday night plans to help with that. And just being available and being readily available and not making excuses or complaints when asked to do something. Be careful with the residents if you have residents at your program, especially with COVID as ORs are limited. I've personally gone from two rooms to one room as we've had limited OR availability, and that does cause some problems with regard to having a resident and a fellow in the same room. And so you want to be careful. You want to take an opportunity to teach the fellow or teach the resident as the fellow. And it's up to your faculty to help organize that so that you get as good of an experience as possible. Don't forget to be a fellow. Remember, you're still a trainee. You're not an attending yet. And so remember to have that respect for your role and what you're doing. Don't slack on the job search. So this has come to bite a lot of fellows in the butt this year, not to their fault, but that's because of COVID and problems with the market and whatnot. So start early if you don't have a job yet. Be flexible to location. You may not get one of those great cities, and you may not get the highest salary, and you may not get that cush ACL rotator cuff job if that's what you want, but you can certainly make that your job in the future, but be open and be flexible and be willing to, to travel to find that job and try to find it early. And we're all here to help you, especially as part of the AOSSM. This comment last year got a lot of eye rolls as well. Be a millennial. I actually am a millennial by, by definition. But what I mean by that is you really want to be careful with some of the tendencies that get grouped toward millennial millennials in general. And a lot of that comes down to social media. So careful what you post, anything you post is permanent. If you did a really great case like salmon fellowship back at rush, and I did a really great cartilage case with Dr. Cole. I don't want to post pictures of that patient, even if it's de-identified on my social media, because that's not my patient. That's Dr. Cole's patient. And we don't necessarily have permission to do that. And you want to be careful with that because anything you get on the internet is there forever, even if you delete it. So just be careful with social media, patient privacy and HIPAA protection is critical. So just be very careful with that. So now to the good stuff. So what do I think are the keys? So be kind. This is common sense, but to everyone, be kind to the people cleaning up your OR rooms, offer to help with the turnover if it's necessary, or even if it's not. Be kind to the admins, the schedulers, the secretaries, the front desk staff. These are all potential people that will influence your career. And it's just the nice thing to do. Be humble. You might be the best technician and arthroscopist in your residency class, or even in this whole fellowship class. But that still doesn't mean you can't make a mistake. I certainly got humbled enough in fellowship, and you shouldn't be afraid to admit that. So make sure you're humble and willing to learn. And remember, if you were an expert on day one, you wouldn't need the fellowship. Be prepared. Know your patients. So you're not operating on a rotator cuff. You're operating on a 65-year-old female, and it's her left arm, and she's left-hand dominant. And what does that mean for her life? Understand these patients because in a year, they're going to be your patients. So know the patients. Know the techniques. If the attending is going to leave the room or leave you to do a case, make sure you know how to do it. Don't just think, okay, I'll watch and get by, or the attending will bail me out. That's always a possibility, but you want to soak this up. You want to be able to do as much as you can. So prepare for the techniques and prepare for the cases, and don't forget to read the journals. Watch the videos. AOSSM has this new playbook with a ton of videos by experts in the field, and obviously there's a ton of other sources throughout the literature and the internet. If anything, that COVID has taught me personally and hopefully has taught our fellows and will teach all of you, be flexible. You may not have the fellowship year that you think you're going to have due to unforeseen circumstances like a global pandemic. So be flexible. A lot of us are type A, and we want to schedule, and we want to stick to it, and we're good at that. But make sure you're flexible because things happen, and you can't always predict that. You've got to be a team player. Help your co-fellow. I can't say that enough. This is a picture from a case where we had three fellows in the same OR because it was a really unique case during my fellowship year. I think it was one of my co-fellows on the service, but he was willing to let a couple of us scrub in, see the case, do parts of the case so that we could all get that experience, and sometimes that's going to happen. So make sure to be a team player. Be a sponge. Soak up everything you can in clinic and the OR. Make sure to take notes and take pictures and take video and don't suffer from the first rotation blues. So say you want to be a hip arthroscopist and you're at the Rush Fellowship and your first rotation is with Shane Ngo and Jorge, and then at the end of the year you haven't done a hip scope in 10 months. Make sure you've taken a lot of notes and videos because that may be all of your fellowship experience, and then you've got to go scrub a few extra hip scopes or do a few extra weeks somewhere to get ready for your job. So be a sponge and take notes and take pictures. Keep a spreadsheet of all your cases. That's going to help you not only to remember what you did during fellowship, but it's going to help you for Part 2 of the board, so I'm going to show you an example of that, and I'm happy to email each and every one of you my spreadsheet. I did this for I think about 100 of the fellows last year after presenting this. Make sure to learn each attendee's preferences. So for my fellows, if you're listening, you know I drape differently than Dr. McCarty, so you want to know how I drape in my OR, and you want to know how Dr. McCarty drapes in his OR. And if you can drape appropriately, then we're both comfortable letting you actually get to operate, but it starts with the little things. And make sure you learn those preferences. Write them down, and you might have to review them before every case the first few times you're on a new rotation. Don't forget about what I like to call the P's, the post-op protocols, the PT protocols, the return-to-play protocols, and preference cards. As you go through rotations, get these, copy these down, get them on PDFs, get them so that you can use them if you like them when you become the attending. These are things you do not want to be scrambling for your first two months of practice. And then finally, remember, everyone gets the same diploma, so all of you in a year are going to be done. You're going to be graduated, and you're going to be practicing. But what you get out of this year can be totally variable. Don't coast, work your butts off like we know you all will, and put in the effort, because this is the last year of your training before it gets real. It's going to be the best year by far, and so make the most of it. Again, I loved fellowship. I'd go back if I could. It was just such a great experience where you don't necessarily have the responsibility, but you get a ton of the autonomy. So it's just a great year, and make the most of it. And this is an example of that spreadsheet. We talked about the patient identifiers, but essentially the things that you want to have on here are the patient's name, some identifiers so you can always go back to the medical record, what you did, what side, what joint, what the diagnosis was, what the procedure was, grafts and implant choices, the anesthesia type. And then when I was a fellow, I would put what attending I work with. Now I put what assistant I have. I keep track of my surgical time, the tourniquet time, and then complications and reoperations. And these are all the things you're going to need to enter in when you enter in your case log for Part 2 of the boards. So if you start making this habit as a fellow, it's going to be very, very, very easy when you start as an attending to just keep your spreadsheet going, and you just enter this either in between every case or at the end of your OR day. So with that, I think that's right at 10 minutes. I'm happy to take any questions, but that's really all I have. And not meant to be intimidating, but I think these are some things that you really want to think about as you start fellowship and just enjoy the year. We're so happy you guys are all part of the SportsMed family. And again, thank you to AOSSM for letting me have an opportunity to chat today. Brian, you're muted. Hey, Brian, sorry, I couldn't hear any of that. I think you're on mute. If you could repeat that. Yes, sorry about that. That was a wonderful presentation. Thanks for doing it. I've got a question from the audience. What is your technique or how would you advise an attending in a difficult moment if you think you might be able to get him or her out of a jam? Any suggestions? So if the attending is having a difficult moment in the case and the fellow wants to try to help with that, is that the question? Correct. Yeah, how would you advise they go about it? I think that's a great question because that happens. That certainly has happened to me. I'm sure it happens to everyone. I think you want to know you're attending, which at the beginning is very difficult because you don't know him yet. Some people, when they get heated, will be receptive to suggestions. Some people won't. And you might make the situation a little bit more hot depending on how you address that. I think in that heat of the moment, you could say, it's with me. Dr. Frank, what do you think about this? I think offering a suggestion and when my fellows work with me, they know that that's 100% acceptable. I love that feedback and open to that. I think sometimes you do have to bite your tongue unless you think there's truly a problem that's going to hurt the patient. And then you have to speak up if you're cutting into a nerve or cutting something and you see that as the fellow, you've got to speak up. But yeah, I think just knowing your attending's personality and being willing to interject at that appropriate time, there's no real strategy for that. It's kind of just knowing. But I would say sometimes the hardest thing as a fellow is holding your tongue because sometimes the attending is just going to get out of it. And they know how to do that. And they've been in that situation before. And sometimes you do add fuel to the fire. So certainly, I can remember from my fellowship year, there's certain attendings you're OK to say that with. And probably some, you just want to bite your tongue a little bit. Good points. One trick I learned and observed fellows do it to me is they ask me, Dr. Forsythe, have you ever thought about doing it this way? Or do you think this might work? So I think a way to disarm the attending who's sort of in need of a moment is to phrase the suggestion as a question. So just take a soft touch approach. And you catch more flies with honey, I think. Another question from the audience. How do you handle a job search request? So if you're with a busy attending, you've got to take off during the week on a busy OR day. What is your strategy? Yeah, I think plan ahead as much as possible. So most job interviews, with very few exceptions, don't come the next day. So you've typically been chatting with that program for a week, or two weeks, or a month. And you pick out a date. Especially now with COVID, things have to be even a little bit more planned. Although, on the flip side, it could be spur of the moment if something opens up. But I think forward communication is key. We all understand that one of the goals, if you don't have a job coming into fellowship, is to get a job. And we all can survive without the fellows. We are grateful for your help. We like to emphasize, at least at Colorado, this is more of an education versus service type program with regard to the fellows. We have APPs. We have residents. We can find ways to survive. And so I think forward communication, making sure if you know next Friday, which is one of my OR days, and I happen to have two rooms where I do really benefit from having the fellow, and in turn hope the fellow gets a good experience, you say, hey, Dr. Frank, I need to get a job. I've got this job interview. This is the only day they can do it. I'm gonna see if I can get a resident to cover, one of my co-fellows to cover, but there's a chance I might not be able to. Is that okay? And I can't imagine any faculty is gonna say, no, that's not okay, particularly in this market where it's so hard to get jobs right now. Good answer. One more question. Suppose you have an issue between fellows or between fellows and residents, and it might involve OR coverage or game coverage, and you just come to an impasse. Would you recommend that fellows sort it out amongst themselves, or do you think you should involve the program director, and if so, at what point? Yeah, that's a good question because there's a lot of the undercover discussions where, say, a fellow is assigned to a team, and one of the residents also helps with that team, or another fellow is available, and for whatever reason, the covering fellow can't make it, and they might not involve the attendees who are ultimately responsible for the team and just figure it out amongst themselves, and I think on occasion, that's good, and if the attending doesn't necessarily need to be involved, that's okay. I think when that becomes habitual or happens every Friday night during fall for Friday Night Lights or every Saturday morning for training room coverage, then it does become an issue. I think as the fellow who is responsible for that team, it's your job to tell the attending covering that team. I wouldn't necessarily go to the program director. So, for example, I cover the Rapids, and if a fellow is helping me and is expected to be there and they persistently can't make it and there's an issue, I don't need them to go to McCarty, my program director, to tell them about that. They can come to me. I think you should do that earlier versus later because this reaches ahead come winter, come the holidays, come other times when people get suddenly busy, when team coverage with hockey, end of football, start of basketball, and college sports becomes really busy, so I would just involve the attending who takes care of that team. I don't think you need to go to the program director, although you should always feel comfortable doing that. Those are great observations. I think we have time maybe for one more question, looking at the clock, maybe one after that. If you were to prioritize the most important aspect of fellowship, what would you say it is? Is it acquiring a sound technical skill set? Is it finding the job that you want? Is it publishing, promoting your academic career? How do you weigh those options and priorities, and what has served you best in the long run? That's a great question, and I think that's different for different individuals, depending on what your strengths and weaknesses are coming into fellowship. I would say the number one thing out of fellowship is learning your clinical indications, when to operate, when not to operate, and how to manage complications. If you can master that, by the end of fellowship, you will be, if not an adequate, an excellent technician from a surgical standpoint. That's just by sheer volume of being in fellowship. You certainly wanna master those skills, but there's always time for labs. There's always time for additional training. When you're first few months in practice, you're most likely gonna be slow, and your reps will be very happy to take you to the lab and practice techniques and whatnot. So my number one priority for you guys, for sure, is to master the indications, the contraindications, and managing complications. That will serve you well, particularly in your first year in practice. Equally as important, because you gotta get a job, is the job search. Don't stress about it your first month in fellowship. That's not the time. Stress about becoming a good fellow. But that should be on your high list of priorities. And then I think publishing, academics, presenting, I'm biased, I'm into all that, but that's lower on the totem pole with regard to the other priorities, for sure, and that should never take the place of clinical experiences, clinical time. I think for those of you who are hoping to cover pro and college teams, getting that team training experience, learning how your attendings work with the trainers and the agents and the coaches, and getting a feel for how that works is really important. Those are things as residents, and if you're not involved as a fellow, you don't really pick up, and those are the critical parts of being a team doc, in addition to, of course, providing the clinical care. Thank you, Rachel. On to the next subject, but I think you summed up everything you need to know to be a good fellow really succinctly, and you articulated all those thoughts incredibly well. So it was great having you, and we hope to see you again. So thanks again. Take care, guys. So that was some really good advice. I hope you guys took some notes. We're gonna now segue into the more topical part of the evening's program. We're gonna have three professors present in sequence. They are live, they are actually recorded presentations, but we're gonna have a half hour to discuss those audience questions. So please, guys, get active, start typing, because we're gonna have a very boring 30-minute time period if we don't get some questions on these great cases. So we'll start with Xavier Simcock. He is an assistant professor at Rush. He specializes in hand and wrist injuries. After Xavier, Dr. Jeffrey Dugas, who was one of the OGs of this program, it was his brainchild, I believe, five or six years ago to put on this fellows course, which has been invaluable as a stepping stone for all of you this year. He'll discuss elbow injuries, and following him, we'll have Dr. Samer Hamoud, who will discuss high-risk stress fractures, which you probably don't see too many of over the course of your residency training, so pay attention, because when you're managing those high school and college teams, you're gonna have a lot of responsibility and you wanna make sure that your athletes aren't being over-trained. So with that, we'll start with Xavier. I should also mention that Dr. Dugas is the fellowship program director at Andrews Sports Medicine Orthopedic Center in Birmingham, and Dr. Hamoud is an assistant professor at Rothman in Philadelphia. He's a team physician for St. Joe's and the Philadelphia Phoenix. So we'll hand it off to Xavier next. Hi, my name is Xavier Simcock, and we will be talking about hand sports injuries. To give you an overview, first we'll highlight extensor tendon injuries, followed by PIP dislocations, the thumb omiclateral ligament, scapoid fractures, and scapolubate ligament tears. 20 to 25% of all injuries in athletes involve the hand. Obviously, there are specific considerations to each case, whether these are athletes at a high level, whether they're in season, whether it's their dominant hand. And for each individual, the treatment goals we won't go into in this talk, because this will be a high-level talk, but kind of pointing out the highlights. We'll focus here on this complex anatomical structure, which is the extensor tendon complex. Specifically, we're going to be focusing on the central slip, as well as the distal terminal. The mallet finger is by far the most common tendon injury in an athlete. It's caused by a forced DIP flexion with active extension. This often happens with baseballs or softballs. In that forced flexion, the terminal tendon is torn or fractured. You get a very reproducible exam, which you have an extensor tendon lag, and they are tender right at that distal crease in the acute setting. Plane radiographs are crucial to make sure that you get a perfect lateral of the finger. This can often be difficult unless you're ordering a finger x-ray or using line fluoroscopy. The treatment for a mallet finger involves six weeks of extension splinting. It's very important to set expectations so your athlete knows that they're likely to be stiff after this interval and that they may have a residual mild lag. After these six weeks, then they will go into a night splint for six weeks. During that six weeks, there can be considerations that some can return to play in this stack splint or extension splint. If they are not treated or ignored, unfortunately, they can develop a chronic mallet, which ultimately can lead to a swung neck deformity, which is difficult to treat. Operative indications for these cases do exist where you have a fracture involving 40% of the joint surface, which leads to volar subluxation and therefore requires either a screw fixation or transarticular K-wires. Unfortunately, the vast majority are fixed with transarticular K-wires, and those cannot return to play. Central slip, I will caution you to be highly aware of the swollen PIP joint. The vast majority of these often present as kind of benign injuries, and you're thinking this is just a small sprain. These happen, again, with forced extension mechanisms, but usually in bigger ball sports like basketball or volleyball. The exam is tenderness directly at the PIP joint, but, however, that's mostly swelling dorsally. There are more involved tests like the Elson test or the START test that can be very helpful. However, to be frank with you, these are difficult in a patient that has acute tenderness, and therefore, X-ray and MRI are very valuable. I highlight here to you the classic nature of this injury in which you see there is just dorsal swelling. You do not see volar swelling with these. In treating, the vast majority can be treated nonoperatively, especially if there is no contracture. This is involving an extension splint for six weeks with a DIP-free and then followed by a nighttime splinting. There are indications for surgery. This usually involves a bony avulsion or the inability to maintain an extended finger, and, again, if these are missed, a chronic boutonniere is an incredibly difficult problem. PIP dislocations, a vast majority are dorsal. Some are lateral or rotatory, which can be very difficult to reduce because the bone will buttonhole through the extensor tendon aponeuritis. These usually are fixed on the field, and what you're looking for afterwards is whether there's an extensor tendon lag, and, again, we're looking to see if the extensor tendon is violated. Thoracoscopy can be very helpful to assess for stability, and it's also crucial to make sure not to miss any fractures, which, therefore, a CT scan can also be valuable. The vast majority of these are treated nonoperatively as well. It's an extension splint. If they are unstable beyond 30 degrees despite reduction, then they should be seen by a hand surgeon acutely, especially also if there is a fracture. It's important to note that early range of motion in these is key to get the athlete back to play with full range of motion, and so buddy taping can be very valuable. If you start buddy taping earlier than splinting, even at a week, you can see that 90% of people return to full motion as opposed to 60%. Again, if these are missed, unfortunately, a swan neck deformity can occur, and this can also lead to a very difficult surgical problem to treat. The ulnar collateral ligament is what we'll talk about next. These have a classic presentation where they're tender on that ulnar side. Usually it's in the distal insertion where they're tender at the vast majority. They can have a stent or lesion in which the ulnar collateral ligament flips out over the aponeurosis, and you can feel the mass there on exam. If they have 30 degrees of instability, that's usually our indication to consider intervention. This can be hard to test without fluoroscopy, and furthermore, it can be very valuable as an MRI in the plane of the thumb. You can see here dynamic imaging at the top where you have fluoroscopy, but you can also see the value of the lateral because if there is volar subluxation of these injuries, these are especially hard to treat. The vast majority are treated nonoperatively in a hand-based thumb spica splint. They can actually return to play in the splint. There is operative indications for people that have a complete injury with a gross instability, a stent or lesion, or a bony avulsion. If these are missed, unfortunately, you can lead to very early arthritis, which those can no longer be treated with a ligament stabilization and need a fusion. The scaphoid is the next topic. The amount of displacement of a scaphoid fracture is key in order to defer its treatment as well as the location of the fracture. The location of the fracture is incredibly important based on its vascularity. A distal or tubal fracture of the scaphoid almost always heals with nonoperative treatment because it has excellent vascularity. A waist fracture can often heal nonoperatively with high rates of about 60% to 80%. Proximal fractures, however, are completely the opposite because of the poor blood flow. Then 60% to 80% of these will have a chance to go on to avascular necrosis with just nonoperative treatment. The index of suspicion for a scaphoid fracture has to be very high. It can be tenderness dorsally at the anatomic snuff box, rollerly, or with a little bit of deviation. It's critical to get a good scaphoid view, which is a pronated view with all no deviation. You can see here that really helps delineate the waist of the scaphoid, so you can see fractures that can hide. Fractures can be incredibly subtle on x-ray, and so a CT scan is something that almost 100% of the time we obtain in our treatment algorithm for CAT scans. As you can see, proximal holes can hide on you as well. In addition, there is a role for MRI, especially for athletes, because it can help delineate what exactly is causing the pain when x-rays and CT scans can be negative. Overall, scaphoid treatments, you can treat nonoperatively in a cast for 6 to 8 weeks based on the location of the injury. Operative indication exists for displacement as much as 1 millimeter, and also for potential earlier return to play. There are case reports of returning to play in 2 to 3 weeks in a hand-based splint with fixation. However, the majority of impact sports, most likely you're looking at returning to sport in 6 to 8 weeks, and we use a follow-up CT scan to assure that there is bony bridging of greater than 40% at the fracture site. Finally, we're talking about the scapholumate tear. You can see here the scapholumate ligament here. This is a similar mechanism to a scaphoid fracture where you see a fall on an outstretched hand. They are tended to a patient, and they have this classic test in the scaphoid in which you see a positive shift, which is the Watson test. Imaging, it's very important to get bilateral imaging here, and also with stress views if you're going to obtain those, because there can be variation among people, what is their kind of normal ligament at the scapholumate interval. MRI is almost used 100% because it can help to identify if it's a partial or a complete tear. The treatment for scapholumates is highly variable based on if it's acute or chronic, but, however, it's good to know that acute diagnosis of these is critical in order to get a patient returned to full play at an earlier point. If you can find these within four weeks and there's no stiffness in the capsule, they do have a very high rate of repair as opposed to needing a ligament reconstruction, and thus we can usually get those players back to full activity. So, in summary, good x-rays are always critical in being able to understand these injuries. These can be dedicated thumb or finger x-rays. Fluoroscopy is a very good friend of yours when trying to appreciate dynamic instability. Treatment is highly dependent on the patient and the position and the goals. Lots of hand injuries can be ignored, but it's good to know that 20% to 25% of all injuries for athletes do involve the hand, and most hand injuries do require mobilization, prolonged mobilization, in order to allow for the best impact for them. Thank you very much. Hello, this is Jeff Dugas from Andrews Sports Medicine and the American Sports Medicine Institute in Birmingham, Alabama. I'm going to talk to you about evaluation and management of common elbow injuries. My disclosures relevant to this talk are that I am a consultant for Arthrex, and I do receive a royalty stream from Arthrex on a product mentioned in this presentation, namely the SoftAnchor. ASMI receives research and education support from lots of people, including Arthrex, Smith & Nephew, MyTech, Donjoy Stryker, and Zimmer Biomat. Case 1, AK, 12-year-old left-hand dominant gymnast cheerleader with a six- to eight-month history of pain and swelling in her dominant elbow. She denies a single injury other than a locking episode several weeks ago and no other elbow history, and she reports that she's unable to do gymnastics activity due to pain. Examination is notable for a normal carrying angle, no obvious effusion or other bony abnormalities. Her range of motion is different from the opposite side, lacking about 13 degrees of extension and about 10 degrees of flexion compared to the opposite side, so a total of about a 25-degree loss. She has full pronation and supination bilaterally. She has minimal crepitus with range of motion and pain at the extremes of motion only on the left side. Pain to palpation laterally at the joint line is present, and she is strong throughout with a normal neurovascular exam. Here are her radiographs, and I will call your attention to the AP view and the abnormality that you see here on the lateral side of the elbow. This MRI, done without contrast at an outside location, demonstrates a capitellar OCD with a cartilage fragment missing. You can see the radiology symbol with the arrow pointing to where the cartilage defect is. So, this is a 12-year-old with a loose fragment in the elbow. In my opinion, there's no benefit to non-surgical management because this is not likely to improve with time, rehab, or injection. We could treat conservatively for the remainder of the season and treat her post-season, particularly if there was a life benefit of continuing the season to perform. That is to say, if there was a scholarship on the line, a state championship, Olympic hopefuls, or collegiate opportunities, or a professional level where there is a financial incentive. Certainly, this has been around for six to eight months, and maybe the loose piece is new, but if she had some real benefit, I would consider waiting for treatment. We get asked the question about the role for biologics. I certainly don't think biologics will replace the cartilage nor put the piece back and will not make the loose fragment any less dangerous to the joint. So, she gave up the remainder of her season. We did an elbow arthroscopy and removed the loose body. We debrided the OCD back to a stable rim and did a microfracture of the capitellum along with a bone marrow aspirate and concentrate injection from the ipsilateral iliac crest. We placed her in a brace for six weeks with range as tolerated, but no weight bearing on that side, and she gradually returned to normal strength through plyometric exercise and PT and strengthening and returned to gymnastics at six months post-operatively. Case 2, LD, is a 39-year-old right-hand dominant female tennis player with a two-year history of right lateral elbow pain. She has had a previous corticosteroid by her PCP and is now unable to do ADLs, play tennis, and has pain at rest. She is healthy, normal to inspection, full range of motion, and her strength is weak and painful to resisted third finger extension and supination. Palpation is she has sharp pain on the lateral side, but no palpable defects, and she is otherwise neurovascularly intact with no effusion. These are her plane radiographs, which in my opinion are unremarkable. These are two images from her MRI. The one on the left shows some heterogeneous signal at the proximal aspect of the extensor mass, and the one on the right shows the same with a fat-suppressed image. This demonstrates some significant abnormalities at the origin of the extensor tendon. So what are our treatment options? Non-surgically, there are many. We could go back to corticosteroid and PT. We could do a biologic. We could do some form of exogenous treatment or needling. There are several ultrasound-guided treatments that have been promoted, and all of these things have a success rate that is variable, but certainly has been successful. Surgical management is certainly an option if you feel that she has failed non-operative management and she is unable to continue to do regular activities. Unfortunately, the real patient had had eight previous corticosteroid injections by her primary care physician with the same history otherwise. So I would tell you at this point that going back to that, or even considering a biologic in that environment is not likely to be helpful. So I would be curious as to your thoughts about the surgical indications now. Certainly this is a biologically challenged environment. So I repeated her MRI with contrast, and you can see here, especially in the middle slide, that she has a very high-grade partial tear of the proximal origin of her extensor tendon. This represents an actual tear rather than a micro-tear of the proximal tendon. I think the role of non-surgical management here is limited, but certainly biologics could have a role. BMAC, PRP, certainly not a bad option. I chose the surgical option, and I used the soft anchor here, and this was my disclosure. We put her in a wrist brace, a cock-up wrist splint, and a sling for six weeks. We started resistance after week eight and plyometrics, and she returned to tennis at four months and competition at five. My thought here in the education point is be careful of the biologic environment for healing. Case three, 17-year-old junior javelin thrower with collegiate aspirations with a two-week history of medial pain after a meet in March of 2019. Felt pain with one throw, but doesn't recall if there was a pop, no neurologic symptoms, and has pain with throwing since the episode. Examination is essentially normal, but he has pain with a moving valgus stress test as well as a milking maneuver, and there's pain to palpation of the medial elbow near the sublime tubercle. X-rays appear normal, and his MRI shows some partial thickness injury to the distal UCL at the sublime tubercle. So this is an acute partial UCL tear. What are the options in this throwing athlete? Well, certainly non-surgical options are available. Biologic options like PRP or BMAC are certainly thought of here. Even though BRP tends to be a little more successful proximally, it seems that in this athlete in his junior year, in the spring of his actual season, cutting bait and going to surgery would seem aggressive. And so certainly a biologic option like PRP would be possible. Surgical options are certainly there, but in my opinion that might be a little aggressive for this injury. We certainly don't know if that injury that we see on the MRI is the first time he's had this. And so giving it a chance to get better without surgery is probably indicated. After six weeks of rest and plyo as an interval throwing program, he returned to javelin in the summer of 19 and the state invitation in late June. Again, he felt the onset of pain, this time with a pop. He had the same examination, except now he had a little bit of ulnar neuritis for a week after the injury. The question is, what do we do next? Well, I repeated his MRI, and although these are oriented differently with the ulna up and the humerus down, you can see all of the periligamentous edema in the flexor mass out here on the right side of these images. And it appears that some of the contrast is escaping from the joint there. So this may represent a small full thickness tear of the UCL. Again, we think non-surgical or surgical. Well, this kid actually did have a PRP injection initially and got back, but in the end it wasn't successful. And so I think non-surgical options have been exhausted here. And surgical options probably need to be considered, particularly in the summer before his senior year. This is his injury. You can see the distal avulsion of the UCL right off of the sublime tubercle. This is the ulna humeral joint here. And you can see here we did the internal brace repair for the distal UCL tear. Case four is a 37-year-old right-hand dominant male with a six to eight week history of worsening pain in the posterior right elbow with resisted extension. He has previous elbow pain with heavy lifting, but no treatment. He enjoys lifting weights, exercising, and plays golf. And he now has pain with light exercise and rest, and he can't lift or press. And he reports pain posteriorly and points to the tip of his elbow. On inspection, he has a little bit of bursal swelling, but no redness. His range of motion is lacking about 15 degrees of extension on that side relative to the other side. He has pain and weakness with resisted triceps on that side, but is otherwise strong. And he is very tender to palpation over a bony prominence at the olecranon tip and the distal triceps, although there's no palpable defect. He's otherwise intact. So these are his x-rays, and these are fairly typical for these type of patients. He does have a little bit of arthrosis in the ulna humeral joint. He's got a proximal spur on the posterior tip of the olecranon. But he also has a posterior olecranon spur at the triceps insertion that you see here. And it's possible that he may have broken that loose right here. That may be an acute injury. So we ordered an MRI, and these are the sagittal images. And you can see that there's some not very healthy-looking tissue down here and an acute injury right at that bony prominence. And it appears that he has avulsed off at least a sizable portion of his distal triceps tendon. So what are our options? He didn't avulse off the whole thing. He's young and healthy. It certainly isn't retracted, and the tendon quality appears good proximally. He's healthy with good bone. Is there a biologic option here? Could we try something percutaneous, a stem cell injection or a VMAC, maybe a PRP? And are there surgical options? Well, maybe there's one other thing to consider. Well, what if it's this guy? Now, I can tell you that this guy weighs about 270 pounds and lifts at least twice that. And he's not about to give up his gym-related activities nor his professional activities that require a lot of strength and a lot of pushing and pressing. And so does that change your mindset as a sports medicine physician with regards to non-surgical and surgical options? This guy needs this elbow to do his job. So what are our best options? Well, I did an arthroscopic excision of the olecranon tip spur, and his range of motion returned to three degrees of extension after the scope. We did an open excision of the ulnar enthesophyte at the triceps insertion. 75% of the tendon insertion intact deep to the osteophyte. And the remaining 25%, which was carefully elevated, was repaired back to bone using a soft anchor. Put him in a brace for six weeks, and he began strengthening. And he was back in the ring at three to four months. Case number five. 51-year-old right-hand dominant manual laborer with a weak history of pain in the anterior arm following an incident where he tried to catch something falling off a shelf that weighed about 100 pounds. He denied any previous elbow issues. He lifts weights regularly and has had no issues until now. Can't do curls without sharp pain. Inspection is normal except for some faint bruising and echemosis in the anterior and medial forearm. His range of motion is normal. His strength is weak deflection and supination. He's stable, and he has a positive hook test. So here are his x-rays, which are essentially normal. And here's his MRI showing a distal biceps rupture with some proximal migration of the tendon. Now there's been some talk lately about non-surgical management for this. And certainly in some people, this might be okay. So non-surgical management might include a biologic. It might include just a brace. And we've seen some reports of excellent outcomes with non-surgical management. However, what if it's this guy? And maybe that 100 pounds was 300 pounds. And maybe it didn't fall off a shelf. Maybe it was somebody's life he had in his hands in this position. And if he drops him, that guy might have a pretty bad neck injury. So is it okay for this guy not to have a normal biceps function? I would think not. So he underwent a two-incision distal biceps tendon repair and returned to full in-ring activities at four months post-op. Could he have done okay with non-surgical management? Maybe. But I think because of the demands on his body, he was definitely better off treated surgically. Case 6. And this could be anyone. A 17-year-old high school football player sustains an elbow injury on the field of play when a player landed on his outstretched arm with his palm down and another athlete landed on the lateral side of the same elbow. He comes to the sideline reporting pain, holding the elbow in 30 degrees of flexion. He's neurovascularly intact but reports some transient ulnar nerve dysesthesias for a few seconds after the injury. He has a little bit of weakness to grip, APL, FTP, and wrist extension, all due to pain. His intrinsic function is normal. And he has 4 plus over 5 biceps and triceps, again due to pain. He has tenderness to palpation medially and laterally and pain with a valgus but not varus stress. Range of motion is painful and he lacks a few degrees at the extremes of flexion extension. So what's our diagnosis? Well, it's probably an elbow subluxation. Is it possibly a transient dislocation? It is. And so you need to obviously look for that. And this is a picture of how I like to do elbow reductions in a dislocated elbow. So what you'll see here is the patient is supine. This can be done on the sideline. The person that's reducing it is on the left. And he's basically putting his hands around the upper arm and using his thumbs to push the olecranon, which is usually posteriorly directed. Most elbow dislocations are posteromedial and posterolateral. So you're using your thumbs to guide the olecranon tip back in. And the other person that's helping you is pulling on the forearm. Now the elbow is usually in about 30 degrees of flexion when this is done. You don't want to do it at high degrees of flexion. So if it's out, you obviously are going to put it back in. But what if it just subluxed? If it just subluxed and he's a little sore, could you get the range of motion back? Could he work it out in the next few minutes? And what if the coach calls you and it's a playoff game or comes over and says, look, this is my best running back. Can you put him in a brace dock and let him play? Well, in the event that you happen to have had the foresight to bring a hinged elbow brace with you, maybe you could. My thought on this is in a stable elbow post subluxation or even simple dislocation, I'm not opposed to letting them go back to play if they can protect themselves in a brace. So I'm not opposed to it if they have normal hand function, good range of motion, and aren't unstable through a range of motion. I would certainly make them play in a brace. I would say that at the high school level, it would have to be a playoff game or maybe last game of a senior year or something that was really meaningful like a state championship to do this. Otherwise, I would hold them. At the college or professional level, you'd have to assess the situation independently, and each situation is going to be different. I think for a full dislocation, I would probably hold them. For a not full dislocation, I might consider letting them go back if they're comfortable enough to play. Which brings up our last case, a 19-year-old right-hand dominant male with a three-day history of pain in the right elbow after jumping over a fence and landing on his outstretched arm. He told me that he may or may not have had a couple of beers before this happened. He suffered a complete dislocation of his right elbow requiring reduction under sedation, and he denies any previous elbow injuries. Inspection showed he was very swollen and echemotic. He held the elbow at 45 degrees of flexion, wouldn't even shake hands with that hand. He was very tender to palpation over both sides of the elbow, particularly at the epicondylar areas. His range of motion was considerably limited, 25 to 95 actively and not much more passively. His strength was very limited by pain, but he was able to resist in all planes, and he had no endpoint to medial or lateral stability testing with a normal neurovascular exam. So here are his x-rays, which, again, are pretty normal. And here's his MRI. If it was a knee, I would think this looks like a knee dislocation, and as an elbow, it certainly does as well. One of the highlights to this on the image on the right is the radial head seems to almost fall away from the capitellum a little bit here. This is because of the lateral-sided injury, which is really important to pick up. With this lateral-sided injury, this person is at high risk for having a late posterolateral rotatory instability, and so this is not just a simple elbow dislocation. This is a little bit more complex. So is there a role for non-surgical, or should we consider surgical management here? My thought on this is with a lateral-sided injury, this is a very unstable elbow, and in the long run, the likelihood is that this is going to cause some problems for this guy on the road. He's likely to get some late PLRI, and just like in the knee, lateral-sided injuries are much easier to repair acutely than they are to reconstruct them later. So I think this is a surgical indication. With a high likelihood of symptoms later with PLRI, I decided to go with open stabilization on both sides. I repaired the lateral side first and was able to repair the entire sleeve back to the lateral epicondyle. I included the lateral collateral ligament along with the lateral ulnar collateral ligament and the lateral capsule. I then opened the medial side and repaired it back to the medial epicondyle with an internal brace augmentation and did an ulnar nerve transposition. Of interest, I think it's important not to close the lateral side until we complete both side repairs. We put him in a brace for six weeks and did plyos and gradual strengthening, and he was back to full activity by four months in a brace. So I want to stop there, and I want to say thank you guys for attending. I hope you have a terrific year as fellows, and I hope that you will participate and become active in the American Orthopedic Society for Sports Medicine. This is our society, and it's important that you, the new members of this society and the new generation of people that will take on sports medicine, participate and become active members. Thank you, and have a great year. Hi, I'm Dr. Samrahmood. I'm going to talk to you today about high-risk stress fractures, evaluation, and management. These are my disclosures. They're not relevant to the talk. We're going to go through the definition, what makes them high-risk, diagnosis, as well as treatment. So definition is really when this dynamic balance that exists between microtrauma and accumulation really outweighs the host bone's repair processes. There are various things that can tip the scale. Intrinsic factors such as menstrual patterns, metabolic state, fitness level, lower limb alignment, bone vascularity, muscular loads, and fatigue. Extrinsic factors include training regimen changes, nutrition or diet, footwear, and playing surface. What makes it high-risk? The three main things include the poor healing potential of that area of bone, which tend to occur in relative vascular watershed areas, the likelihood of progression, including fracture displacement and nonunion, as well as the high refracture rate. These are the high-risk stress fractures we're going to talk about today. They tend to present the athlete's full complaint of insidious onset of pain over two to three weeks. It may be accompanied by a change in their training or equipment. It's important to obtain a thorough history, including medical dietary medications. Make sure to ask the female patients about their menstrual history. Physical examination is relatively consistent with tenderness of the affected bone in functional testing, such as hop testing, which exacerbates the pain. Initial assessment can be done with an X-ray. It's easily available. It's very cheap. It may be normal initially, something to keep in mind. You can repeat it after two weeks if you have a high index of suspicion. In many athletes, if you shut them down quickly, you may not ever see a positive finding on an X-ray. Bone scan can also be very sensitive. If you really need an urgent diagnosis, this can be helpful, but it's nonspecific. It's certainly lower cost than an MRI as well. If you have multiple fracture sites throughout the body, this can be very useful. MRIs tends to be the imaging method of choice beyond an X-ray. It's sensitive and specific, gives you greater anatomic detail, and allows for soft tissue evaluation. CT scan, although it has a higher radiation dose and lower sensitivity, can be very useful in post-operative evaluation of union. Electron stress fractures, they're the most common in overhead-throwing athletes. Originally described in javelin throwers by Wares in 1946, the mechanism is valgus extension overload, or triceps traction on the electron during deceleration. There's several most common types of fracture patterns, either the electron tip transverse or oblique. It's important to evaluate it for associated ligamentous or intra-articular pathology. Non-surgical management can be successful with relative rest, avoidance of throwing for six weeks, plus-minus bracing or immobilization. It's important to remember that the electron physis typically closes around the age of 16, but it can be persistent into adulthood in a small percentage of patients, and these are typically bilateral. If you see an electron stress fracture, as in the left-hand X-ray there, getting a contralateral X-ray in a patient can be very useful to determine whether it's a persistent physis or a pathologic fracture. Treatment typically involves a single compression screw across the fracture site. Patients will typically achieve full motion by eight weeks, strengthening and kinetic chain improvement at eight weeks, and throwing program starts around three months, final return to play usually around six months. Thermal neck stress fractures, anterior groin pain is the most common complaint that's exacerbated with weight-bearing pain at the extremes of motion, MRI showing a hip effusion, certainly keep a close eye on those. Those have a much higher rate of progression of fracture and need for further surgical intervention. Compression site is the most common. You can treat it nonoperatively if it's less than 50% diameter of the neck. Tension site, get surgery. They have a high risk of displacement, high risk of delayed union, nonunion, varus deformity, and osteonecrosis. Patellar stress fractures are rare. There are some typical risk factors, but it's important to keep in mind that those risk factors do not need to be present. It can simply occur from overtraining. Nonoperative treatment, if x-rays are negative, you need to avoid painful activity really until they're asymptomatic. This can take quite a long time, and so operative treatment in the high-demand athlete to improve or shorten the time to return to play is certainly important if they have a significant finding on x-ray. Surgical fixation with cannulated screws and tension band fixation is appropriate. Intertibial cortical stress fractures are common. The anterior cortex is under constant tension. Tension from the posterior muscle group has poor vascularity in this area. There's a very high risk of completion of fracture and open fracture. They tend to have tenderness over that middle third of the anterior tibia. Fulcrum tests can be positive as well as a hop test. X-ray can show just periosteal reaction in the anterior cortex, and the worst finding is a dreaded black line as you see in that x-ray. Nonoperative management can be successful, but it can be really a protracted course up to a year or more, so it causes a prolonged time out of sport. There's a risk of delayed union fracture completion. Operative treatment is typically with tibial IM nail or compression plating. High-level athlete considerations, both the two. Intramedullary nailing is better for multiple or noncontiguous fractures but can result in anterior knee pain. Compression plating gives a biomechanical advantage but can have a high risk of symptomatic hardware needing removal, and you can't really use this in cases of multiple fracture lines throughout the tibia. Navicular stress fractures occur typically in the central third of the navicular where there's maximal shear stress across it. It's typically lateral to the center of the tail or head. There's an area of poor vascularity here as well as the abnormal shear stress in this area. You have to maintain a high index of suspicion in the patient that has dorsal foot pain over the navicular. Nonoperative management involves strict nonweight-bearing with casting six to eight weeks. Typically, surgical is with compression screws, percutaneous versus open. Typically, there's an initial period of nonweight-bearing followed by progressive weight-bearing and gradual increased activity starting at around eight weeks. It's not uncommon also to get a CT scan prior to really increasing their activity level to confirm union. A Jones fracture is most common in basketball, football, and soccer players. It can present after an acute injury but can also be a slow prodromal progression of symptoms. A physical examination involves point tenderness at the base of the fifth metatarsal. Pain is worsened with weight-bearing and foot infusion. Non-surgical management could be considered if there's no intramedullary sclerosis. It needs a strict nonweight-bearing for six to eight weeks. If the athlete is just at the completion of their season or with enough time to recover, this can certainly be considered. Surgical management tends to be the mainstay for the elite athlete in terms of return-to-play considerations and timing. Intramedullary sclerosis on x-ray, one should also consider surgical management or persistent pain or subarthrosis despite conservative treatment. Surgical management is performed really to decrease the risk of nonunion refracture as well as to decrease the time to return to play. The technique is a solid four-five screw trying to fill that medullary canal. Recovery involves, again, a period of nonweight-bearing followed by full weight-bearing by around six weeks and increase in activity at eight weeks. Pain should be resolved and radiographs should demonstrate healing. Medial malleolus stress fractures are uncommon. They tend to occur in running and jumping athletes. The cause is a repetitive impingement of the talus on the medial malleolus causing vertical shear stress in this area. If plain radiographs are negative and the fracture is incomplete on MRI, you can treat this conservatively with activity modification, a short-leg walking cast or ankle bracing, but it really can take up to five months or more to heal. In high-level athletes, if x-ratio is a complete fracture line or there's a nonunion or failure of conservative management, either cancellous screws or an anti-glide plate are appropriate methods of fixation. Great-toe sesamoid stress fractures occur in athletes who have sudden start-stop sports. The medial sesamoid is typically involved. It's larger. It's positioned directly under the first metatarsal head. Mechanism tends to be repetitive great-toe dorsiflexion, which results in tensile forces causing a transverse stress fracture. Consider other associated conditions such as gas rock contracture, pes davis, or plantar plexus first rays. There's typically pain with direct palpation of the sesamoids, pain with great-toe MTP dorsiflexion. X-rays, AP, and sesamoid view would be important to get. An MRI can show edema and necrosis and give you more information. You have to differentiate these from bipartite sesamoids. Look for presence or absence on the contralateral side. 80% of them can be bilateral in a bipartite setting. Callous formation, regular unequal fragment diastasis, all of those things would suggest more of a stress fracture. Certainly a bone scan as well can help to differentiate. Treatment as non-surgical. Rest and non-weight bearing for up to eight weeks. Short leg cast to prevent dorsiflexion. You can switch them into orthotics as well. Surgery to avoid the high risk of delayed union non-union refracture. Involves bone graft and aureus. Non-surgical. Rest and non-weight bearing for up to eight weeks. Short leg cast to prevent dorsiflexion. You can switch them into orthotics as well. Thank you very much. I'm back on, I think. Thank you, Drs. Amu, Dr. Dugas, and Dr. Simcock, those were fantastic presentations. We're going to have one more esteemed guest before moving on to the panel discussion. Next we have Dr. Ned Amendola, who is a past president of AOSSM, bringing some significant gravitas to the evening's program. He is a professor and chief of sports medicine at Duke, and he's going to educate us on common injuries of the foot and ankle in sports. Thank you for having us, Dr. Amendola. Oh, thank you for having me on the show. I guess my video has some glitches in it, so I'm going to give my presentation live. So do I have to do anything to get my... You can take care of it. Okay. Is that good? Everybody can see the screen? You're good. Yeah, we can see it, and I love the beard. We're in a war right now. When we get rid of COVID, I'm going to shave. Anyways, this is great. This has been a great symposium, and I wish all the incoming fellows a great year. I think it is the best year that you're going to have, and enjoy it. Take everything in. So 10 minutes to talk about foot and ankle injuries. I really don't have any conflicts with this presentation, and I think we're all familiar with that a lot of sports injuries involve the foot and ankle. Based on all these studies, more than a third of all sports injuries in weight-bearing sports involve the foot and ankle. They're the most common cause of time loss from sport. And the important thing to remember is that every one of these injuries is a spectrum of severity. In other words, there's mild injuries, there's severe injuries, and I think some of the other speakers have kind of alluded to that. So you need to individualize your treatment regimen based on the severity of injury. And that's where the hard part comes in. And so how do you make effective decisions on return to play? Well, you need to understand the pathophysiology of the injury. How bad is it? Is it stable or unstable? Is it high risk or low risk like Dr. Amoud presented in the last presentation? So there's generally a key point or a key question that you're trying to answer with every one of these situations to make a decision if they can go back early, or if they need extra time, or if they need surgery for that particular injury. In my opinion, these are the five most common injuries that we see. I'm not going to talk about stress fracture since it's been covered well in the last presentation. And we'll just go over these very quickly and briefly. So here's an example of an ankle sprain. This was a female collegiate basketball player, an acute inversion sprain, normal x-rays, and was expected to return within a few days or maybe a week, but then was unable to return, was able to return for the NCAA tournament. So what went wrong? Well, when you look at the x-rays, they do look normal. When you look at these normal ankle, there really doesn't look like any obvious fracture. But as we investigate her further, when she wasn't able to return, you can see there's an anterior process fracture of the calcaneus. And you can see the MRI and the CT scan, it's quite a large fracture. And that explains the reason why she wasn't able to return and we fixed it. And she missed that season, but came back after that. So the key question with ankle sprains is really, is this an isolated injury, just a sprain? Or is there some other associated injury that's preventing return? If it's an isolated ankle sprain, you can usually let these kids return to play as tolerated within a day, within a few days, within a week of the injury. This is a diagram from Ian Alexander's book, Foot and Ankle Examination. And again, the most common reason for missing extra time following an ankle sprain is a missed or associated injury. So you got to look everywhere around the ankle. You got to look at the medial lateral malleoli, look at the talus, look at the anterior process of the calcaneus, look at the base of the fifth metatarsal. Anyways, a complete examination will allow you to make that determination. We'll move on to high ankle sprains, which is really a continuation of the ankle sprain. This is another reason why ankle sprains don't return to play is because there's a syndesmotic component to the injury. And you can get a syndesmotic partial injury with an inversion sprain as well. It's not the routine thing, but you can see here the distal portion of the syndesmotic ligament with a severe inversion sprain, you can tear some of these fibers. And so you can have a little bit of a high ankle component with an inversion sprain, which will prevent a regular sprain going back to play. The usual way these occurs with external rotation. So you can get an injury that goes at the distal part of the anterior tip of the ligament and can go in the interosseous membrane, including the posterior tip of the ligament. So the severity depends on how severe the ligament has been injured. Here's an arthroscopic view of a normal end of the tip of the ligament. This is, you know, vast as part of the ligament that you can see, as I was pointing to earlier. And when you have high ankle sprains, obviously it can be a severity of injury. You can have just a few fibers torn, as here it says no instability. You can have more significant injury with some instability. You can see some of the diastasis between the tibia and fibula. And then you can have complete injury with the lateral movement of the talus and fibula with respect to the tibia, as you can see here on the right. And so it's important to know what's involved in the injury. So the anterior ligament, the posterior ligament, the interosseous membrane, and the deep deltoid. And so again, the severity of injury depends how bad the injury is. So you can just have a little bit of the AITFL injured, and these kids will get better within a few days, a week, at the most two weeks, and get back to play. But if they have more significant involvement, it's not going to get better within a week or two, and you may have to do something more aggressive. And that's the problem with syndesmotic injuries, is we don't have a really good test to tell how bad the injury is. So if you have normal x-rays, you know, what do you do? Well, you have to look at the injury mechanism. You have to examine them and re-examine them every few days. Look at an MRI, do stress x-rays, and look at their functional progression. If they're not progressing, you got to suspect that it's more of a severe injury. Here's an example of a severe injury. There's actually a little bit of widening here immediately, so you can tell this is more severe. This was our quarterback. This was back in 2009. You can see the edema at the attachment of the syndesmotic ligament posteriorly, which indicates that it may have been injured. And here's the MRI, which shows the posterior ligament is not totally off, but it's partially avalanched. The anterior ligament is torn. So there's some stability there, but it's not completely stable. So we decided to treat him aggressively with surgery. I don't know where the surgery video went. And he played it five weeks, and we won the Orange Bowl. He was the MVP of the Orange Bowl. So I think it's important to try and make that distinction of a stable versus unstable injury. Here's an example of a lineman who had a significant injury, but was diagnosed as a mild injury. This was the senior year of high school. He sprained his ankle. He never really got back to 100%. He was able to play, but he felt he was maybe at 80%, couldn't push off, and couldn't pivot on the ankle. He had mild swelling. It was tender along the syndesmosis. And he had pain with external rotation stress, and the stabilization test was positive. In other words, if you held the tibia and fibula together with tape, it kind of relieved his pain and made him more stable. Here's his X-rays. You can see his mortise is normal. He did not have any fractures. But here you can see the calcification. After five months, he's got a lot of calcification. So he's tried to stabilize his ankle himself. So here's five months later, and he's still not 100%. So that's the question. Would he have benefited from early treatment right after the injury, or one week after the injury to stabilize the mortise? Here's a CT scan. You can see the calcification between the tibia and fibula. Here's the video. This again is at five months following the injury, and you can see the anterior ligament is completely absent. There's increased space between the tibia and fibula. So there is some instability there, but we just, or whoever was treating him was not able to detect the instability on X-rays. So you have to use everything in your power to determine that. So we excised some of the calcification and treated him with syndesmotic stabilization. We'll go on to left sprank injuries, and this is similar to syndesmotic injuries. It's definitely a spectrum of severity. The injury on the right is a motor vehicle accident. The injury on the left is a football player. And again, this is a typical injury we see in sports is a mild sprain, is a disruption of the syndesmotic or the left sprank ligament between the middle cuneiform or the medial cuneiform and the second metatarsal here. You can see the lateral displacement of the second metatarsal. So these are the injuries that we typically see in weight-bearing sports. We don't usually see the injury on the right. Now left sprank injuries are important because the medial column of the foot provides stability. If you don't have stability in the medial column, you can't push off. And so the left sprank complex right here provides some of that stability. So it's important to make sure that it's stable. We all know how these happen with both direct and indirect injury. Axial loading of the foot can happen with a crush injury. The injury may extend into the intercuneiform joints, as you can see here. And again, when you see these on x-ray, if they have diastasis like this, they need surgery. If you don't see diastasis like this, what do you do with these? And that's the point of this presentation. So I think it's important to do weight-bearing views. The weight-bearing views may not tell you the whole story. If you still suspect an injury, you should do stress views. And again, an MRI may be useful as well as a CT scan in assessing the left sprank complex to see if it's disrupted. Again, we're familiar with the anatomy and the left sprank ligaments here, but most importantly, this ligament between the medial cuneiform and the base of the second metatarsal. This was a study by Steve Raken that showed if you can see this ligament on MRI, then it's stable. If you can't see it on MRI, then there's a question of instability, and you should probably do a stress test to confirm the instability. Again, here's the stress test. This is a cadaver video by John Famino. You can see the abduction stress. You can see the opening between the base of the first and the second. And this is what you need to do. The problem with stress tests is that you need to have some sedation. And so I generally do them under anesthesia with the idea that if they're unstable, I'll go on and fix them if they have positive stress tests. This is a good article to have. This was by Jim Nunley and Chris Bertullo, kind of describing the types of injuries. But again, we're dealing with types one and two most commonly. If it's a type one, it's stable and can be treated non-operatively. If it's a type two, it's unstable and you need to treat it surgically. And so that's the question here. You have to determine if it's a stable injury. If it is, you can treat it with basically some rest for a week or two, gradual rehab. Get back in the pool and get back to activities as they can tolerate. So here's two examples. This is the same mechanism, two football players. This was a lineman, a center who has severe swelling and pain in the foot. He had normal x-rays. As you can see here, the base of the second and the middle cuneiform are in line. All the x-rays are normal. We took him to the operating room and this is a stress test under anesthesia. And you can see there's a little bit of opening, but there's no displacement of the base of the second with respect to the middle cuneiform. So we decided this was stable and decided to treat it non-operatively. We basically did not put any fixation in his foot at the time of anesthesia. Here's another example. Same type of x-ray. It looks pretty normal. There may be a little bit of widening compared to the other foot. And here's the stress x-ray. And now you can see that the first is unstable as well as the second, and it's moving, translating with respect to the middle cuneiform. So we went ahead and fixed that with a lift-spring screw and immobilization. Obviously, this takes quite a while to heal. It's going to take three to six months to get back to full weight-bearing and loading activity. So non-operatively, I think you can be, you know, fairly aggressive with these. If they're comfortable and progressing nicely, you can use an orthotic. If you treat them operatively, I think you have to keep them immobilized for at least six weeks, non-weight-bearing, and then another six weeks of gradual weight-bearing, so three months at least before ground-based training. And then my final entity here is a turf toe. We'll start with this example. This is a college defensive lineman. You can see the bruising. Obviously, this is a significant injury, and he ended up having early surgery because of a complete disruption. The key to diagnosis is any displacement proximally of the sesamoids. You can see here there's proximal displacement of the sesamoids, in particular, the medial sesamoid, and on the sesamoid view on the right, you can't see the medial sesamoid, and the lateral sesamoid is also a little bit proximal. You can do an MRI to confirm the injury. Again, you can see here the different level of the sesamoid and the plantar plate disruption. And again, any displacement, you can see here the displacement. Any displacement, to me, is an indication to fix these. I don't think delaying the treatment is good. I think if you're in a NCAA tournament or something like that, and they can get by for a few weeks, I think that's fine. But generally speaking, these people are having a difficult time pushing off with this injury. And I think early treatment is much better, and the results are much better following early repair. And this is the incision I use. Here you can see that athlete, there's the flexor hallucinus tendon, there's the disruption of the plantar plate. And this is really good tissue. You can bring this together, you can put small anchors into the sesamoid if necessary. And usually these will do very well. And you can be quite aggressive with the rehab, you know, a couple of weeks of mobilization, and then you can use a spring light or a steel plate insert in the shoe, and you can get them mobilized, you know, fairly quickly. So return to play at two to three months after doing surgery on these. So I think you can be fairly aggressive with this type of injury. So that covers those four injuries. Just the stress fractures was the key question, is it high risk or low risk? If it's high risk, it needs surgery. If it's low risk, it doesn't necessarily need surgery, and you can take a risk and let them play with the low risk fractures if they can tolerate playing. But I won't spend too much on that. So in summary, for foot and ankle injuries, you really need to understand the severity of the injury. What's the key question you're trying to answer to get them back to play? You're trying to determine between surgical treatment versus aggressive non-operative treatment or aggressive return to play. And so return to play is determined if it's a low risk of recurrence and low risk of more severe injury. I think you can let them go to play. You can let them play early. You need to clearly communicate what you're trying to do in all these cases. And again, decision-making one way or the other is better than no decision. In other words, it's difficult to waffle. So either you say, okay, we're going to let them play or we're not going to let them play. We're going to do surgery or we're not going to do surgery. But kind of staying on the fence usually doesn't give you much reward from the coach's point of view. All right. Thanks for your attention. Hi, Ned. Hey, Jeff. How are you? Good. What's that? Where's the rest of the crew? That's a good question. There we go. There's Brian. There's Zach. And Summer. All right. Meredith, are we live at this point? Yes, we're live. Thank you. That was fantastic. Xavier, Jeff, Summer, those are terrific presentations. I have a case of my own. I don't think that it's too much of a clinical What I'm most interested in is in how all of you would sort of manage this situation. It's pretty straightforward. I hope we can rip through it in about five minutes or so. And then we can get to the audience's questions. But if you would do me the favor of chiming in and interrupting, I'd appreciate it. I want this to be as engaging as possible. So I have no relevant disclosures. I have a patient of mine who actually saw via telemedicine visit initially in June. So this is a COVID patient. She's an 18-year-old elite gymnast, rising freshman at a Pac-12 school. And she competes in all four events. She presents with, there we go. I'm sharing my screen now. Everyone got that, I presume. So 18-year-old gymnast, elite athlete, going to a Pac-12 school. And she's got a history of a tibia chronic stress fracture. Now, if I can control my screen. On-set of symptoms was in November of 2019. Formal therapy was initiated in 2020, which didn't seem to be too formal as it involved a chiropractor massage and red light therapy. There was pain with impact. She actually shut herself down, probably not by choice as gymnasts always push through. But for two months, she wasn't allowed in the gym. And even that couldn't negate her symptoms. Her past medical history is really non-contributory. She's actually a quite fit. Normal men sees regular diet. She's pretty big for a gymnast, but she is still at the elite level. Her gait is non-autologic, but she's unable to even do a single, single leg hop. So she's got good range of motion of hips, knees, ankles. She's got an obvious prominence, which you can palpate on the mid-shaft of her anterior tibial cortex. And this is what her x-rays look like. Does the panel have any thoughts? I'm going to ask Dr. Hamoud, where should we go from here? So I'm just looking at these x-rays. Obviously you can see kind of some chronic thickening of that cortex. You can almost see, I don't know if this is my projection on the computer, almost two areas where you may have seen fracture lines that appear to be attempting to heal themselves. I think you can get at this point some advanced imaging here maybe a CT scan, maybe an MRI. I'm not sure if the projection is not coming through. When I look at it, you may see multiple fracture lines through that anterior tibial cortex, but I'm not sure if it's the projection here. I think it's probably a little bit of both. I think it may be the projection. There's certainly one that's most obvious at the apex there. I think some of those other lucencies may have been older healed lesions. So obviously we got more imaging. This is a CT scan, which I'm going to scroll through and you can see there's quite a big prominence. There's a bit of a lucency there. It doesn't project too well on a CT scan, but there is a single area that is concerning. So we got 3D recons and this doesn't really help too much other than to show the overall morphology and it supports this being a chronic process. The MRI images didn't project very well at all. So I'm just going to give you the report, but we have a stress fracture, a healing bridge stress fracture, which is evident on both CT and MRI. There's an MRI from two different places. An MRI from two and a half months prior, which shows a re-demonstration of the lesion. There's interval healing, but this seems to be something that's been going on for seven months or so. So it is still an issue. So I discussed with the family, continued conservative versus operative management, which involves nailing or application of a plate along with a referral to endocrinology. So these are our treatment options. We could put her in therapy. We could try something metabolic. We could prescribe her a bone simulator or we could talk surgery. We could maybe give it more time. Dr. Amendola, where would you leave the discussion with the family from here? I think we've gone through enough time. Seven months, you've done everything. You know, you've assessed her metabolic status. I don't know what an endocrinologist is going to do, but I think that's fine. But I would have elected for surgery probably before this point, not to be aggressive or anything, but I personally think that this bone is trying to heal itself. This girl is trying to heal this. You know, it's a hypertrophic. It just needs a little help. So I think it needs surgery. I don't think a bone stimulator is really gonna do it. So you can get this healed. I think you do a bone stimulator, non-weight bearing, non-activity. You'll get it to heal, but then what's it gonna do to prevent this from happening in the future? So I think doing surgery, put an intramedullary nail, don't go through the patellar tendon, just go medial to the patellar tendon, and then allow them to weight bear and do activities immediately following the surgery, I think is the best thing to do. That's a great advice. One of the things, Brian, to add to that is she is a giant among gymnasts. I mean, this girl is gonna have the same issue if we don't handle this. And so I think, you know, she's a rising freshman in college, so you could take the approach that she has five to play four, so you've really got some time. So you could take the non-surgical route, but if you're gambling, you're gambling, this girl's gonna end up with some kind of fixation before she really gets on the mat at the collegiate level with all the demands of that. So with her body, I think she's gonna end up with some kind of fixation one way or the other. I had the same concerns. Well, Jeff, what would your operative technique be on her? Well, I would normally say nail, but she has pretty narrow canal. I think you're gonna put a pretty small nail in that, but I would definitely nail it. I agree with Ned. I wouldn't go through the patellar tendon. I would go medial to it and try to avoid the tendon. Okay, those are great points. Dr. Hamoud, what surgical technique would you pursue? I would agree. I think nailing is best for her, particularly because there is that hint of kind of multiple fracture sites. So I think when you have a singular fracture line, you could consider the plate, but she really has kind of a long area of likely fracture sites that have occurred in the past and maybe healed. So you wanna get across all of those with a nail. Thank you. So any indication for referral to endocrine? I sent her. They told her the next appointment was three months later, so that wasn't a very practical option. But just for the audience, there is some investigation on terapeptide, which is obviously a derivative of parathyroid. There is a randomized trial, which is being conducted and should be completed in the UK next spring. So I'll be eager to see how this might influence our practice going forward. Hey, Ned, let me ask Ned a question, Brian. We've been using Forteo and some of these fifth metatarsal stress fractures and things in the foot and football season, tibial in season type injuries, where the option of not playing for some people is not an option. So how have you felt about that, Ned, for some of the lower extremity injuries you see? I think it's huge. We're pretty subspecialized. To be honest, I don't see too many of the chronic stress injuries. I take care of the Chicago fire, which obviously entails quite a bit of lower extremity trauma. You know, I haven't had a lot of personal experience, to be honest, but I'm not opposed to it. If we can get an athlete back to the field sooner in a safe manner, I'm all for any other modalities. You've done it. It sounds like you've done it with some of your football players. Yeah, how about you, Ned? Yeah, we've done it as well. One of the issues is cost. It's a pretty costly treatment. So I don't know if you guys have handled that. I have, I think it's good. I think, and particularly on the foot, you know, with fifth metatarsal and navicular fractures, you know, sometimes the fracture line, it's partially healed, but it continues to be visible for months. You know, and I think it's useful to do that. Again, to make the point I made earlier, I think a lot of these fractures, you know, so navicular, fifth metatarsal, tibial, mid-shaft fractures, you know, in my mind, you can get these fractures healed, but what are you going to do to prevent them from happening again? So like in the foot, you know, you can use orthotics. For navicular stress fractures, you look for anterior impingement, you know, at the ankle or anything like that that needs to be removed. So always look for an additional reason. What are you going to change biomechanically to prevent the fracture from reoccurring despite the metabolic treatment and healing of the fracture? Great points, Ned, thank you. So there's some controversy as I did a plate. You know, the last gymnast that I did was a tiny little girl with thick cortices and I had a hell of a time getting a nail down, like Dr. Dugas had alluded to. So I opted to do a compression plate. Cosmesis was an issue for her that did not guide my treatment, but I was more concerned with the anterior knee pain. And I guess you can avoid the patellar tendon. I just didn't want to struggle with an off-centered beginning point, which might've resulted in a more challenging procedure. So I tucked that plate in, I kept it low profile, and that is, actually, I could show you a post-operative x-ray. That is how I proceeded. So a week out, her baseline pain level was only two out of 10. She was pretty compliant and I was concerned about her trying to push too much, but she showed up using her crutches. I had her walk and she could walk without an intelligent gait. Otherwise, things progressed well. You can see the bend on the plate. I tried to pre-bend to establish some compression at the fracture site. You can already see a little bit of remodeling, much for how well that projects on that lateral x-ray. So the plan was to focus primarily on upper body conditioning. I wanted to avoid impact. I saw her at one month and she looked terrific. This was just, actually, it was just a week ago. No pain. She was progressing well, full range. Really, you would hardly believe that she'd had a recent procedure, but I still wanted to allow for more time, so I restricted her from any significant impact activity. I'm gonna bring her back in three weeks before she leaves for school. This is what her x-rays looked like at one month, which was just a week ago. So you can see further remodeling and maturation, and to the extent, maybe I did roll the dice a bit, but I haven't had, anecdotally, as reliable outcomes with the nail in terms of post-operative pain. So going forward, I think I'll allow full activity at three months. Any quick comments before we get to the audience's questions? I think this is great, but it continues to be a division, even in professional athletes. I see quite a few NBA players for opinions about, and it's definitely, they get two opinions, either a plate or an intramedullary nail. And I think on six foot five and six foot eight players, I think an intramedullary nail is a good way to go. Maybe this one on the gymnast with the small tibia and the small canal might be a little bit better idea to use the plate. Thank you. I don't think we have the data to tell which one is totally better. Yeah, I would agree. I've got a few questions from the audience pertaining to this case. Dr. Hamoud, what is your algorithm for use of biologics with the initial non-operative management of stress fractures and how do you time surgery? So, admittedly, with the stress fractures in our practice, my primary care colleagues are mainly managing them and managing the biologics. I would say that we don't use them really widely in our practice for the management of stress fractures. In terms of timing, I think after any course of initial conservative management and failure, certainly the different stress fractures are different. So if you see a dreaded black line for a tibial stress fracture, I'm gonna be a little bit more aggressive. I think timing in terms of their season, so if you have a rising freshman like your patient there who has already had some non-operative treatment and is going into a collegiate career, it's a little bit different than maybe a freshman in high school who I may entertain a further conservative management for a longer period of time. I think that it's such an individual-based, based on the sport, the patient, and there are a lot of things to factor in. But again, it comes back to high-risk and low-risk stress fractures, and I'm just more aggressive with those high-risk fractures. Thank you. So I've got a couple of general questions from the audience. One was, could all of you recommend a good book for general sports medicine principles and surgical technique? Could each of you just suggest one? Or if we can get one- That's a tough question. I did have a hand question, though, before that, on scaphoid fractures, since we had a hand presentation. Yeah, I've got a couple in line for Dr. Simcock, don't worry. I'll pick on him in a bit, but this brings to mind that joke that you hear about orthopedic surgeons, right? If you're trying to hide a $100 bill from an internal medicine doctor, you put it on the patient, and if you're hiding it from an orthopedic surgeon, you put it in a book. So we just fulfilled that stereotype. So we're gonna go on to Dr. Simcock's questions, which I have enumerated here. What is your in-season management of scaphoid fractures in football players? What are the safety parameters that you employ? You're on mute. And we couldn't hear you. Yeah, there we go. Okay, sorry about that. Just to go back to the tibia, because Brian, I noticed you didn't ask me any questions. I thought that was the funniest looking humerus I've seen in a while. In regards to scaphoid fractures, it really depends on the position, right? And what their demands are with their hand, if it's a throwing hand, or if it's their contact player. We tend to be very aggressive with scaphoids today, even for minimally displaced ones. And when you see CT scans of even a millimeter of displacement, it raises our level of suspicion that it's not gonna heal. The most aggressive treatment out there is to think about return to play at three weeks with a screw. That is aggressive, right? I think a lot of people are gonna wait to see some bony bridging on CAT scan to feel good about it, because there are rates of not healing with a screw, especially if it comes down to the position of the fracture. If it's proximal, especially we tend to be more conservative. But professional athletes, it's possible to go back if you're on the line and admit within two to three weeks if you're not doing any kind of fine motion in the wrist. So it's unfortunately, there's no perfect answer. I thought that was a great answer, but that was pretty close to perfect. So I'm gonna give you two more to catch you up. Do you let athletes return to a game after suturing small, medium, large hand lacerations? Do you have any general principles or guidelines that you can share with us? Absolutely. So I learned this one in the ER as a PGY-2. I mean, if it's on the volar aspect of the hand, you gotta be really cautious. There's just too many things that can go wrong there, and infections can become a big deal. Dorsal aspects of the hand, I will often let people to go back with small lacerations. And then obviously, as it goes more proximal, you can be more aggressive as well. But I'm very cautious with volar. I'm very cautious over joints. How about web space lacerations? Again, you know, dorsal, I think it's gonna be okay. Web space, it's more management than peeling, right? Because we worry about contracture than anything else. But web spaces, I'm a little bit less cautious with. Okay. Two more questions for you, and then we're gonna move on to the next topic. How do you determine whether athletes can return to competition following a PIP joint dislocation? Just talk us through the red flags and when it's really not appropriate. Yeah, that's a great question. I figured it might come up. You know, if you're on the sideline, and it's not uncommon, if it's a straight dorsal dislocation, you can put that back in, and it's always the pressure to go right back to play. I will caution you if you don't have an X-ray, right? Because I've seen so many times people think it's a simple dislocation, and there's comminution at the joint. It's a bad peel-on, and they have another injury, and then it's gonna be devastating. It can change your career. So, you know, without an X-ray, I would be very cautious. With an X-ray, if you know that you have a simple dislocation, it pops back in, you know, you can return to buddy tape. There's a risk, right? Because you're gonna have an unstable finger, and especially if it's a, you know, a border digit. But if it's a longer ring finger that, you know, and you protect it with buddy taping, it's possible. Great. Last question. Would you ever try to reduce a perilunate dislocation on the sideline in a football game? Absolutely. But, I mean, to know that it's a perilunate, I assume you have X-rays. To know what type of perilunate it is, whether the lunate is fully dislocated, or if it's just hinged, is another concern. And the reality is, even with, you know, good, adequate, like, hematoma block with the lidocaine, it takes a lot of force sometimes to get those in. So, I'm happy to try. I would definitely note your median nerve before you put it in, because the chance that there's been a ding to the median nerve is high. So, if you haven't noted it before, and it's there after you pull on it, you won't feel as smart about it. Great. I'm gonna segue to Dr. Dugas. You had some incredible athletes up there who might've been consuming performance-enhancing substances, whether or not they're legal, I don't know. But how do you advise patients who may be using enhancing drugs, like HGH, testosterone, or anabolic steroids, how do you advise them pre and or post-operatively for a given injury? Well, let me answer your earlier question about textbooks real quick. So, I would say, number one, I would go to OKU Sports. That'd be the first one I would suggest. And the second one I would say is Deleon Drez, the sports medicine book, which Mark Miller helped write, has written a lot, helped edit the last couple of editions. So, to me, those are the two that I think are the most comprehensive. They're multiple, the Deleon Drez multiple volumes, and the OKU Sports gets updated fairly regularly. So, I would say those are the two that I would think about. For the steroid-using group, the first thing you gotta worry about is infection when you're operating on them, their healing capacity. Typically, their skin's not very good. Most of those guys, especially in the powerlifting, wrestling, all these things. Now, I can tell you, working with WWE, we don't have those issues. That's been about 10 years, because we've really gone away from that. But in that world, you're working with people that work in a wrestling ring. So, they're colonized with everything. And you have to worry about just infection as number one. So, every precaution you can take, I put them all on antibiotics for weeks, post-surgically, for whatever it is. Almost all of their injuries are gonna be tendon injuries. And I think when you're repairing a tendon in somebody, or a muscle tendon junction injury in somebody that's a steroid user, you're facing an uphill battle just to get it to heal. The environment isn't great. And you know that those people are not gonna wear their brace. They're not gonna follow the rules. They're not gonna do what you tell them. And they're gonna try to get back in the gym, or the mat, or whatever. So, I think you just have to over-fix those things. So, when you're thinking about, do I have enough sutures in this thing? Do I have enough fixation in this thing? Have I tied them down enough? Have I convinced them enough how bad of a problem they're gonna have if they don't follow the rules we're setting out for them? This is one of those communication things that you have to get with these people, and make them understand that they have put themselves in a position to fight an uphill battle. And the worst thing they can do is try to be faster than where we are. We have to control the tempo of that recovery, and let their body try to catch up a little bit. So, I think between infection prevention, and just over really holding them back, and tying them down, those are probably the two hallmarks of dealing with those things. That was a fantastic answer. Just another quick question. There was a patient that you had presented who had olecranon-versal effusion. Do you ever drain those? And if you do, would you ever inject cortisone? Because I think some of our fellows have been covering colleges, high school teams, where they just wanna fix a problem quickly, and you could predispose to something much larger. Yeah, I think for prepatellar, and olecranon-bursitis, and things like that, yeah, we drain those things all the time, if they're truly just bursitis. That one was, you know, obviously a little more than that. But I don't have a problem draining those things. I just tell them, you got about a 50% chance that this is gonna help. And, you know, I can remember athletes that we've taken care of, that we've drained that thing every week before the game. And, you know, by the end of the game, maybe it's starting to come back. But if that's what you gotta do to get them to play, that's what you gotta do. Our best wide receiver, who ended up actually playing for the Giants, interestingly, you know, got drafted by the Giants and played for them for a number of years. I can remember operatively excising his Bursa, and he played the next day in Tennessee. Actually, the state troopers picked him up from the hotel. He still had an IV in his arm. I told him not to take the IV with the antibiotics going in until they got to Tennessee. They took the IV out in Tennessee and he played the next day. So, yeah, I mean, we deal with those things in the middle of the season because sometimes you just have to. And knowing that you're not really solving the problem, sometimes you just gotta drain it. Brian, my one thing, you know, in technique of draining, I don't know if you do this, Jeff, but, you know, if you're going to go after those, trying not to create a fistula, you know, is important. So, you know, as you go in, you kind of make kind of back and forth kind of a hopscotch as you enter so that when you remove the needle, you know, you don't have this continuous fistula, but that's just a technique referral, yeah. That's a great point. That's a good point. Dr. Simcock, I cannot imagine what some of your partners at Rush would say within the hand division about draining Electron Bursa. Do you feel the same way? I try and convince every patient I see that comes into the office that I'm not gonna drain it because the risk of sinus is real. And if you have a chronic draining sinus, it is a tragic problem. And unfortunately, those often end up in front of us. So you're always treating your last complication. Do you guys ever treat hockey players in Chicago? We take care of the Chicago Steel. We don't do the Blackhawks, but we do see a lot of the junior players. That's why they always came to see us. They don't usually do it on Thursday. Takes care of them mostly. You know, hockey players get Electron Bursitis. You know, wrestlers get Pre-Patellar Bursitis. And I've treated a number of NHL hockey players for chronic Electron Bursitis. It's interesting. I thought you guys in Chicago would know how to treat them. You know what my worst draining sinus was? I had a wide receiver that I hit a bursa pop up right on his chin. He got popped so hard at Marshall that his helmet popped off and went about 20 yards. And he ends up with this big bursa, this big blood filled thing. So this was back almost 20 years ago. So I drained that thing. I stuck a big old needle in that thing and drained it. And of course he gets a draining sinus out of his chin. So, you know, to Xavier's point, you know, definitely got to watch out for that. Right, there's risks to intervening and to not. So two quick questions for Dr. Amendola. When are patients with mild Lisfranc sprains safe to return to sport and what criteria do you use? As I tried to mention in my talk, I think if, first of all, they have an injury that you're suspecting, a Lisfranc injury, I think you should investigate it and make sure that you think it's stable. In other words, I think you should do X-rays, make sure there's no displacement, do an MRI. If you can see the Lisfranc ligament on the MRI, I would consider it stable and therefore mild and therefore, you know, start gradual therapy. These are painful. Even if they're mild, they're painful. You know, they're not going to be able to get back the next day. It's not like an ankle sprain or the, you know, the next few days. They're going to need to be in a boot probably for a week or two. And they can come out of the boot for therapy, you know, icing, they can get into pool, non-weight bearing. But it's going to take for a mild Lisfranc injury, a Lisfranc sprain that's stable, it's going to take probably three to four weeks to get them back to play. Thank you. One, another question, sort of on-field management or training room pearls. Do you subscribe or believe in the sort of one centimeter of syndesmosis tenderness above the tibial tail or joint line corresponds to a week of recovery? Which is something that we often grow about. So if they're tender, three centimeters above the joint line, it's about a three week recovery and so on and so forth. There's that. I don't think that single finding, you can make a decision on. I think you get fooled very easily. I mean, last year I had another case that's obviously not enough time to present. Our center last year had a high ankle sprain in a game, but he didn't complain. You know, he played the rest of the game. Then on Sunday, he says, you know, doc, my ankle's sore. And he's got a little bit of soreness. He says, oh, it feels fine. I can weight bear, I can play. So he plays the next four games. And then the fifth game, he says, you know, doc, my ankle's sore. So we get an X-ray and he's got calcification all the way up and down his interosseous space. We get an MRI and he's actually had an avulsion that's partially healed of the posterior syndesmotic ligament. So, you know, here's a tough kid. He's an NFL caliber kid. You know, we don't get too many of those at Duke. And he wanted to play and he played with pain. But, you know, I think just on that one finding, I think it's difficult to make a decision. I think you should use everything. You know, you should look at the injury. You should examine and re-examine every couple of days. I think that's one of the things, the amount of tenderness they have, the amount of swelling, but kind of put it together with everything, you know, to make your decision. Thank you. Last question for Dr. Amoud. Would you ever inject with lidocaine an athlete with an osteonecrotic bipartite sesamoid to get them back in the game or pre-game rather? Inject with, sorry, you said with? Lidocaine, just for symptomatic relief. Would it be safe or ethical to provide an anesthetic into an osteonecrotic bipartite sesamoids so someone could play the game? So I'm probably gonna volley this over to Ned. You know, my gut says, you know, if it's like, you know, the championship game, it's doable if it's just with a local anesthetic, you know, obviously not a corticosteroid, but I'm gonna volley that over to Ned for the definitive answer. Ned? I don't think it's a good idea. You know, I think injecting local anesthetic to participate in a game is generally not a good idea. I think these days it's probably not the right thing to do. And period. The sesamoid complex, I think if you're gonna inject, you know, xylocaine, you're really kind of asking for a turf toe injury, you know, and get a complete turf toe disruption. So I think it definitely would not do that. So the sesamoid complex, the Achilles tendon, the patellar tendon, definitely no. Jeff, would you have them sign a waiver? Yeah. As I saw you. Some waivers don't do anything for you, but I can tell you that that case came up in the Superbowl when the Falcons were playing and there was a guy with a fibula fracture and it was a Superbowl. And the question came up, do you inject this guy with a mid-shaft fibula fracture so he can play in the game? And my answer was, if you are ever gonna do that, if there is ever an indication to do that, it's the Superbowl. And so that's what happened. And we're not the team docs for the Falcons, but we were asked that question and the answer was, yeah, of course you do. No, but that's a mid-shaft fibular fracture, which is probably, it's a stable injury. Like you can play with it, with or without anesthetic. Obviously the guy was a whiny guy, but he shouldn't be playing without any anesthetic. But so that was a nightstick injury. A nightstick fracture of the ulna is the same thing. It's a stable injury. You can function with it. But if it was a rotational fibular fracture, it came up from the ankle and it came up, there's no way in hell you could inject two tons of anesthetic, you wouldn't be able to play. Well, and I just wanna say, so I'm getting texts from Pete and Delicato while we're sitting here. And Pete, since I know you're watching and Ned's smiling, Pete is a, for all you new fellows out there, Pete is a former president of this society. He's known as the Godfather. He's a Paisan, he's an Italian. And he doesn't have to be watching this right now. But the fact that a former president of this society is sitting here watching this discussion speaks volumes to the nature of this group and what it means to all of us. So, you know, it's just a cool thing that Pete's watching and Pete, I hope you're doing good, man. Thank you, Pete. So with that, I'm gonna have to turn this over to Dr. Bryson Lesnack. He's an associate professor at University of Pittsburgh, team doc for the men's basketball team there along with Carnegie Mellon. So he's gonna talk about shoulder injuries. This is a fantastic panel discussion. I can't thank you all enough for taking the time to join us. All right, thank you. Bye you guys, good to see y'all. Likewise. Hello everybody, this is Bryson Lesnack coming from University of Pittsburgh. Thank you for coming to the AOSSM virtual fellows course. It's a little different this year since we're obviously can't be all together in Chicago where we can do some hands-on stuff, but thank you for participating anyway. And we have a truncated lecture this year compared to most. So bear with me if I go through this a little quickly, but we'll get through this and hopefully have some chances to discuss things later on in the kind of overall review and discussion sections of the course. So overall, we're gonna talk about some case-based shoulder things, right? Shoulder instability and rotator cuff being the two most common things you're going to see in your fellowship in the coming year. You guys just did your boards, the boards answers to questions better than any of us that are giving these lectures probably. So I'm not gonna belabor those points. I'm gonna go through some of the case-based things and hit the high points that you're gonna need to know for the next 12 months and hopefully things that you're gonna use the rest of your career. And so the real kind of controversies with shoulder instability really come down to first-time dislocators, operative versus non-operative management, arthroscopic versus open Bankart repair, kind of what is old is now new. People are leaning more towards open repair techniques in certain situations, rather than when I was a fellow, everything had converted to arthroscopy and it was arthroscopy no matter what, because open was kind of for the old guys. And then we're gonna talk about on-track and off-track lesions because it's something you're gonna hear a lot about and something you're gonna have to know about in terms of humoral and glioid cytoplasm. So first-time dislocators, what do I tell my patients? Well, the highest risk for failure of non-operative treatment are all pretty consistent. They're young, they're male, they usually play a contact or collision sport and they have continued apprehension with their exam. And the numbers I usually quote my patients are, if you're under 20 years of age, you have about a 90% chance of recurrence after a one-time shoulder dislocation. If you're between 20 and 30, I usually quote them 80%. 30 to 40s, I say, yeah, you're 50-50, it's a flip of a coin. And anytime you get over 40 years of age, you have a low risk for recurrence actually, but your big risk in that age group is concomitant rotator cuff injury that you have to see, recognize, and address relatively urgently. And then you always have to remember how the timing of an injury and timing of the season and the sport that they play impact the decision-making. What sport do they play? What position do they play? What symptoms do they currently have? And the risks of non-operative treatment during the rest of the season or in the off-season I think are all important you have to consider. So the unfortunately named Incivility Severity Index score, the ISIS score, which came out in 2007, really looked at retrospectively a bevy of 134 patients that had arthroscopic bank heart repair and said, okay, who are the people that are failing? Who are the people that are doing well? And can we rank score that or summarize that somehow? And what they found was that the mean score of patients that had recurrence was over six. And the mean score of no recurrence was 2.7 out of this scale of zero to 10. And so what they found was if you had three or more points on this 10 point scale, you had a 5% chance of redislocation, which is really pretty reasonable and comparable to open. If you had six or less, so between three and six, you were somewhere around 10% risk. If you had greater than six of these 10 points, you had a 70% increased risk of recurrence. And the main thing really, the main takeaway from this is, consider an open bank heart repair in the teenaged competitive collision athlete, especially if they have any glenoid bone loss. So you guys have just taken your boards. And so you know that the board's answer for critical bone loss is somewhere between 20 and 25%. If you have 20 and 25% of glenoid bone loss, the answer is to do an open procedure, whether that's a Latergé or an open bank heart or some sort of augmentation. In 2015, JT Tokish and a group of his colleagues in Hawaii said, let's look at this. Is redislocation really the only definition of failure and the only definition of doing poorly after arthroscopic bank heart repair? And what they found was, they found obviously similar to the other studies, which showed that greater than 20% bone loss led to a much higher dislocation rate, redislocation rate after arthroscopic repair. And under that, you had a more reasonable amount, 7.3%. But what they found was, in a group of patients that didn't dislocate, it was really a cutoff of about 13.5% bone loss of the glenoid, which resulted in worst postoperative outcomes. So not necessarily instability, but poor outcomes according to the SANE test and the WOSI shoulder score. And so it's important to know not just redislocation is failure. If you don't get back to the things you want to do, especially in the high level population, military, et cetera, you can't get back to those things. Even if you don't dislocate, you've had a not optimal outcome. And that kind of transitions us to talking about the glenoid track. And that takes into account both the glenoid side and the humeral head side, right? And we have to figure out what does this on-track, off-track stuff mean? Because it's become very predictive in terms of failure of arthroscopic bank heart repair in an isolated setting. And so the main takeaway points are all Hillsex lesions engage with enough force and mechanism. That's what happened in the first place. They engaged in the first place and they created that defect. So keep that in mind. Truly engaging lesions are ones that do so after you do the bank heart repair or when translation is possible beyond the glenoid rim, wherever that rim is now, whether or not there's bone loss. And then you need to assess the Hillsex post-repair and doing that is the same as the on-track concept. So if you fix the repair and then you check the Hillsex, if it engages, that's off-track. If it doesn't engage, that's on-track. And how you can measure that is by doing this. This is a 3D CT scan, but you can see you've got the glenoid width and it's usually right around 30 millimeters if there's no bone loss. Whatever that width is, whether if there's bone loss or if there's not bone loss, you take that measurement on the CT scan and multiply that by 0.83. If that number is higher than the number between G and R, or if you want to get really fancy, you can look at this here. If 83 minus D, if D is the potential bone loss, if that number is higher than R to G2, then you're on-track and it's a stable lesion and you can do an arthroscopic repair. If G2 to R is higher than 83 minus D, that's an off-track lesion, that Hillsex will engage and you should consider doing either an OPRA procedure or perhaps a REM massage to augment your arthroscopic thing. And we'll show that in a second. And so basically you can have this proposed algorithm where you have four groups. You have glenoid defect, and I would have this as 20%, not 25 these days, but you have a small glenoid defect or quote unquote subcritical less than 20 with an on-track measurement. You have a small defect with an off-track measurement, a large defect with an on-track measurement, and a large defect with off-track, which makes sense. In each one of these groups, there's some general recommendations, right? Small glenoid bone defect with an on-track lesion, you can do a scope repair and be okay. A small lesion with an off, a small glenoid defect with an off-track lesion, you've got to do something more than the scope REM massage. And number two could be REM massage, could be an open REM massage isolated, could be an open REM massage with a scope REM massage if you want. And it could really be a Latter-J if you want to be pretty aggressive. Group three, which is a large glenoid bone loss and an on-track lesion, most people would do a Latter-J because restoring that glenoid bone will then make that a pretty stable joint with a now quote unquote continued on-track lesion. And then if it's off-track with a large glenoid defect, not only do you have to replace the glenoid bone loss, but you also have to address that Hillsex defect and potentially do a REM massage at the same time. Or you can do an augmentation of bone on the humeral side with an allograft or something like that. Okay, so that's kind of the treatment algorithm. And so here's an example of that, right? I have a 15-year-old female basketball player, has had two dislocations, most recently was approximately three weeks before seeing us in the office, had been treated with physical therapy in a home program and had failed that because she had a subsequent re-dislocation. The physical exam was pretty nondescript, normal range of motion. She actually wasn't that lax. She had two out of nine Baten criteria. I assume you guys know what that means. No real impingement signs. She was apprehensive, negative jerk test. So it seemed to be a pure anterior instability pattern. Here's her x-rays, really looked pretty normal, reduced shoulder. You don't see a large, don't see necessarily a super large Hillsex defect. Here's her MRI. As you scroll through, you see a displaced anterior Bankart lesion that's medialized along the medial neck. Really the rest of the joint looks pretty good. She has that Hillsex lesion you can see in the back, but it's small. You can see the one coronal cut. You can see the extent of that Bankart tear there and her superior labrum is okay. So the questions that I would normally have for you guys to talk interactively about would be what are our treatment options here? Is non-operative still a role? Is there still a role for this young girl that's had multiple dislocations? My treatment plan was not to do that. I don't think there's a role for once you've had more than one dislocation and a teenage competitive athlete. So I measured everything out. It was an on-track lesion, no glenoid bone loss, purely a soft tissue injury, except for the Hillsex defect, which was on track. She had multiple episodes and she's young. So we proceeded with arthroscopic Bankart. Now I have video of this, but again, in the interest of time, we kind of are skipping ahead. This is her scope looking from the posterior portal here, obviously glenoid and humeral head. You can see that her superior labrum is okay. Her posterior labrum was okay. Her anterior inferior labrum was torn there. That's before preparing it. We then prepared, sorry, let me get that out of the way. We then prepared her anterior labrum with a debrider and an elevator and other instruments and got that labrum floating up to the glenoid rim, nice and anatomic, and then proceeded to march from inferior to post, sorry, from inferior to superior, tying knots to the anchors as we marched up, resulting in an excellent kind of capsular placation. The key here, obviously, is to not only repair the labrum to the glenoid, but also to bring the capsule from inferior superior and shifting the capsule, tightening that anterior band of the inferior glenoid, which is what we did here. And she's done pretty well. That's an old technique because I don't tie sutures anymore. So she's about a year and a half out and she's doing pretty well. Case number two, this is a 30 year old Marine. So he's a little older than our first patient, but his first dislocation was when he was 18. It was a high energy mechanism of injury. He's had five dislocations since then, most recently about a week and a half before I saw him. Describes continued apprehension with his arm above his head. He's had no treatment whatsoever, except for some PT when he was in the Marines. So he's an athletic guy, 175 pounds, six feet, no baiting criteria, so he's not lax. Preserved motion and strength. Definitely has some apprehension. He's guarded load and shift, and his posterior load and shift is a little bit lax, but nothing too unreasonable. These are his x-rays. As you can see, he has a larger indentation, a larger sign of a possible health sac lesion up there on the AP view. The rest of his x-rays look pretty good. You could argue, and I know what's happening next, that there's some softening of the cortex up here and the anterior inferior glenoid, so maybe he has some bone loss. He's also had five, six dislocations, so that's when you have to start thinking about some glenoid bone loss. Sure enough, here's the CT scan that I got based on the MRI. As we scroll through, you can see that bony bank cart that's probably chronic and not healed there. As you scroll through, as we get to the CT, you can then see the coronal section. You can see the bone loss there, which I did measure. MRI showing kind of the A-bare view. You can see the bony bank cart tear right there. Oh, sorry, the one last axial cuts. You can see the labral tear pretty well. The posterior labrum looks pretty good. So here we have a 30-year-old male with chronic right shoulder dislocations and instability. It's his dominant arm. He's in active military. He's 30, so he's a little bit older. He's got a 15% bone loss, so above that 13 1⁄2%, and he's got a Hill-Sachs lesion. So what do we do about it? What are our options? Well, you could offer him a bank cart repair. You could offer him a bank cart with REM massage. You could offer him an open bank cart repair. You can do a Latter-J, a Bristow, a distal tibial allograft, any one of these things, and you can open grafted hemodefect. All of those are possible. Our discussion was to do an arthroscopic bank cart repair and a REM massage. He's got 15% bone loss on the inferior aspect of the glenoid. He's got an off-track lesion, so his Hill-Sachs will engage. So my rationale is to do a repair of his bank cart and then do a REM massage, utilizing the bony transfer procedures as a bailout in this case or as a subsequent revision situation if he fails the arthroscopic approach to his shoulder. There is a paucity of evidence for any one of those things. You could have answered, if we did a poll, you could have answered Latter-J and been correct. You could have answered open shift and been correct. You could have answered how I did, which is arthroscopic repair and REM massage, and you would have been correct. Not a single one of these is in the literature superior to the other, and there's ongoing research, obviously, to try to answer that question. And so in the interest of time, I'm gonna skip through these videos really pretty quickly. There's just the view of his anterior shoulder looking through the posterior portal in a lateral position. Really, there's no labrum to speak of. His capsule is really pretty beat up. There's really not much labrum to speak of, and we're gonna do mostly a repair of the labrum, or excuse me, a repair of the capsule to the glenoid. There's his hill-sax lesions, pretty large, pretty impressive hill-sax lesion. There's his rotator cuff that's fine. The cable looks good. So that's just a quick diagnostic scope there, putting in our, us putting the cannula in. But once we put the cannula in and we start working, I'm looking with a 70-degree scope now down the medial neck of the glenoid, and you can see, really, there's not much good tissue there. Once I elevate down here, we'll be able to bring up some of this capsule labrum, and it'll look a little bit more normal, but there's not much there to go on. And so you just have to kind of start digging around and start elevating things up. And as you elevate that labrum, as you elevate that capsule inferior, or medially, I should say, and inferiorly on the glenoid, normal-ish tissue will start elevating back up. It'll start floating back up. You can see there's some labral tissue up there floating back up to the glenoid as we release around that inferior neck. And so that's what we're doing there is just preparing the labrum. Now, as we're looking from the front and working from the back, you can see through our posterior portal our debriders in there, and we're gonna start debriding that Hillsex lesion and getting it to a healthy, bleeding, bony surface. So I've prepared the anterior labrum and capsule, and now we're preparing the rempossage. And that's the general kind of method, the approach that I take. Prepare both surfaces. Don't pass any anchors yet. Once I debride the rempossage, I then go ahead and pass my anchors percutaneously. So not through the posterior portal, but percutaneously through skin and caps, I make stab incisions. So I pass with spinal needles first, and then I put a drill guide over that area percutaneously, and I pass anchors, one inferiorly, and you can see the anchors there, and then a second one goes in superiorly there, and I've got two anchors in the Hillsex defect for eventual repair of the rempossage, and you can see that's the drill guide. I leave the drill guides in there, and then when I'm in the subacromial space to tie these anchors up, I can find the sutures easily with the debrider and not have to worry about cutting the sutures with my debrider, because I have the metal drill guides in there. So that's what I do. Then the next step, sorry, the next step after that is to fix the bancardi anteriorly and the glenoid, and that's what I'm doing here. And it's the standard kind of bancard repair. You try to get, in this case, as much capsular and labral tissue as you can, although it's not great, and I bring everything up and basically just repair the capsule and the labrum to the glenoid, which you can see there. So we're just marching up from inferior to superior again. This is in the lateral position. So that's the last anchor going in. It's a knotless going in there and tying that off, and so then I come into the subacromial space, clean up all the bursts. I did have some subacromial bursitis, and this gets a little bit tricky, but you can use a lateral portal, just like you're doing a rotator cuff repair. You can use an anterior portal, but whoops, you got a little, there we go. So you can see now I'm coming down with my debrider. I'm looking from the front with a seven degree scope, working from the lateral portal. You can see my drill guide's still in there protecting the suture, and so I know where to find my sutures. And so then I can dissect around that with the debrider, you can see I'm grasping around the drill guide, pull the drill guide back, and I've got the sutures in my grasp where I can pull those out. Then once I do that, I can place a cannula in the back of the shoulder through that same posterior incision. You can see my cannula there, and I grab both pairs of sutures, one from the inferior rempelsage anchor and one set from the superior rempelsage anchor, and I pull those through the cannula, and then I tie them to each other, tie the superior anchor to the inferior anchor, and then I go back and tie it, thus kind of completing the rempelsage. Then you can go back into the joint. Once you tie that knot, which I just did there, you go back into the joint, you can see there's a rempelsage there with the capsule now embedded nicely into that hillsex defect. And if you internally, externally rotate, you'd see that that's positioned well in that hillsex lesion, then preventing it from engaging, okay? And so that's that rempelsage technique. That's just, this is a quick kind of just picture summary of it. Same thing, the hillsex lesion, debriding it, preparing it, passing all the anchors, and then doing your rempelsage. So last case for shoulder instability, 21-year-old offensive lineman. This is basically a posterior instability case. You can see his posterior labral tear there, and he also has a posterior capsular tear. And so this is what we did. You can see the posterior labrum in the first picture. There's his capsular split. And what we did was we prepared the labrum, did the same thing, marched up the side with anchors, and then did some side-to-side, two side-to-side sutures, repairing that kind of posterior capsular split, resulting in a kind of combined, excuse me, capsule and labral repair. So moving on to rotator cuff, decision-making and controversy. The big things to talk about are acute traumatic rotator cuff tears. They are not the same animal as a degenerative 75-year-old lady rotator cuff tear. And then the massive rotator cuff tears. Not all massive rotator cuff tears are the same. Always have a backup plan, always have tendon transfers or a superior capsular reconstruction or a reverse total shoulder in mind when you see these things happen. So the acute traumatic tear, if you get to it within three months, they do better than if you get to it after three months. And that has to do with mobility of the tissue, with atrophy of the associated rotator cuff musculature. And that's been shown multiple times. Most recently, the other thing that you can see is with acute massive rotator cuff repairs being done well, you can really correct pseudoparesis and pseudoparalysis going from 35 degrees of forward flexion to 165 degrees of forward flexion if you get to it within three months. So this is a perfect example of that. It's a 56-year-old female who slipped and fell at home. She had continued pain, weakness, inability to forward flex her arm past 20 degrees, although passive motion was reasonably intact. Had horrible rotator cuff strength. So the differential is big cuff tear. She could have a great tuberosity fracture that includes the cuff insertion, a root injury or a plexus injury or a cuff contusion. X-rays look pretty good. She doesn't have a fracture. Here's her rotator cuff imaging looking at the sagittal views of massively retracted rotator cuff tear in all planes. Slip scap actually looks okay. Big anterior humeral head cysts which you have to worry about when you're passing anchors. And it looks like she has a lot of atrophy, but it's just that retraction. And so that's the diagnosis. Massive cuff tear. You can do all of these things which we talked about. So what I propose to do is an arthroscopic rotator cuff repair with the tenodesis and the biceps and always have the possibility of doing a superior capsule reconstruction as a backup. Everyone has a plan until they get punched in the mouth. Don't get punched in the mouth and be unprepared. Have some backups for your fellowship year when someone asks you, well, what do you do if this fails? So this is her case. Again, I'm gonna go through it really pretty quickly. This is her biceps looking at the joint. We did a biceps tenodesis which I'm doing there. As I skip through, you can see, we're just kind of attaching the biceps down with an anchor. And as we move forward, now we're in the subacromial space and we're cleaning up the acromion there. I don't do subacromial decompressions routinely. So we didn't do one there. We clean up the insertion of the rotator cuff there on a greater tuberosity. So that's what I'm doing there. This is the part that takes time. Take your time doing it. Some of the fastest surgeons I know, when they say, take your time with this, that you should really listen. Because if they take their time with it, that means that it's really important. If you don't get a nice bony bed to heal the rotator cuff down to, it's not gonna heal. It's gonna fail at three, six months when you really start moving this again. So you really get a nice bleeding bony bed first with your RF probe. Then I take a burr or a debrider on burr setting, just a one direction setting. And I don't decorticate it completely because I don't want that bone to be too soft, but I get a nice fresh bleeding bony surface there. Now you can see the rotator cuff pretty well. I have to debris a little bit more away. You'll see it there. So there's a rotator cuff really retracted to the level of the joint line. You can see it's a big, looked at first to be like a big U-shaped tear. But in actuality, when you pull, the posterior is much more mobile than the anterior, which is common. So this is more like an L-shaped tear. And we're gonna have to bring some of this posterior stuff more anterior as we tie the, as we put the anchors and tie this up because the anterior part is just not as mobile, which is really quite common. And you'll see that a lot. So we start marching our way from front to back, putting anchors in the shoulder, along the articular margin and passing them one by one. I won't belabor these points, but you're just passing with a suture passing device through the cuff tissue, putting another anchor in the back. And we use three, in this patient, I think we used three anchors on the medial row and two on the lateral row, just passing more and more anchors because it was really supra, infra, and part of teres minor that was all torn. So there we're just passing anchors. So once you have all your medial row anchors passed, you can do knotless. I still tie the medial row, especially with these large tears because if the lateral row fails, especially when they have this poor bone quality, big cyst in the head, if the lateral row fails, you don't have to start all over again. You've got tied suture that is at least holding a single row repair for you. So keep that in mind. So I tie my islet sutures down, but I still use those sutures as a second row. So that's what we're doing there. Then I start coming back to the lateral row. The visualization is gonna be a little tricky, guys, because I'm just going through this really quick. So I apologize for that. Went back, went a little too far. We've got a nice lateral row repair. Put the two lateral row anchors in, cut the sutures, and then you'll be able to see towards the end here as we put this last anchor in, a nice kind of lattice, that typical lattice looking structure of a double row repair. And the tear that was all the way to the joint line, you might not think a tear this large could be repairable, but it really can be in the acute setting, which is nice. Okay, so that's what that looks like. So massive rotator cuff tears. Definition is not well understood or not well agreed upon, I should say. It's anything from five centimeters to two or more tendons. The important thing is that size does not mean, size does not equal repairability and vice versa. Massive tear isn't necessarily irreparable, and irreparable is not necessarily massive, okay? A second case, really quickly, 48-year-old right-hand dominant fell under her left shoulder five months prior to the, fell onto his left shoulder five months ago. Similar story, terrible motion, actively but passively fine. You can see in this gentleman, when you move his arm up, the left one just doesn't go, okay? That's pseudoparesis. His x-rays looked really pretty good. MRI looked remarkably similar to the last one we saw, except for now this is five months old. And so you can see there's some atrophy setting in, but not terrible. Actually looks better than our last patient's MRI when you first look at it. So I'll skip through this, but same treatment algorithm. Problem is, totally immobile rotator cuff, the tissue quality was poor, and so superior capsular reconstruction was done after bisecting. And so you can see us already putting anchors in the glenoid here for the medial row, and then establishing some anchor position for the lateral row. This is the superior capsular reconstruction going in. Not fantastic pictures, I apologize. The video is much better, but you can see here, this is the superior capsular reconstruction medially here and then laterally out here. And this is after you do the lateral row to get your final superior capsular reconstruction repair. And then this is him three months post-op doing passively, doing really quite well. And that's what the literature shows. The literature shows that these do really quite well. The first description of this being by Mahada in 2012 using a tensor-facial autograph, but then this has been repeated with allograft here in the States showing really pretty reasonable restoration of function in terms of forward function and even external location. And there's that using, this is using allograft. Okay, so conclusions. There's controversy exists within the shoulder as well as any other joint in sports medicine. You must use your literature to individually approach each patient and have a plan. Pays close attention to glenoid and humeral bone loss when deciding on approach to instability. Fix acute rotator cuff tears acutely within three months for sure, some say six weeks. Not all massive cuff tears are equal. And good luck in your fellowship year and subsequent careers in sports medicine. And my apologies for going a couple of minutes over. Thanks guys. If there's any questions, I look forward to chat with you maybe in some of these breakdowns. Otherwise send me an email. I'll be happy to answer any questions you have and good luck. Bryson, that was terrific. I think I'm back on. Couple of quick questions for you from the audience. What is your take on all suture knotless anchors for shoulder instability? Do you think that literature offers much clarity and what is your personal approach to it? Yeah, two different questions there, I guess. What does the literature tell us and what's my approach? So first, I don't think the literature does provide us much clarity. I mean, I think over the last couple of years at AOSSM and other places, there've been a lot of equivalency studies done. You know, this is equivalent to that. This approach is the same as this. There's not a lot of definition in terms of one being superior to the other. I try to still do some knotted techniques with cup and with instability for sometimes no better reason other than to teach the fellows and give them reps and tying. But that said, I have found some advantage, especially in instability and with slap repairs using knotless techniques. I do think you can get some scar tissue above those big knots that you can tie arthroscopically. So above the equator of the glenoid, I almost always do knotless. And I've even gone to doing knotless kind of below the equator with some of the new anchors that you can really get a nice capsular shift and a really nice bumper with good tension, sometimes a better tension on the suture with a knotless technique than you can with me tying knots arthroscopically. So really it's, to me, the literature isn't good enough. You say whatever's best in your hands at this point, I think. I think you're spot on. One quick comment from my perspective, I think your approach angle, whether you're using an accessory seven o'clock or trans subscap portal is probably more important from a technique and outcome standpoint versus what widget you use, whether it's knotless or peak or bio, I think really getting things reduced anatomically is paramount. Another question is, are you calculating the on off-track parameters for all of your stability patients or just when you have patients with significant bone loss, say 10, 20%? Yeah, so another good question. Academically, I do it for every one of my patients just to do it and to keep my residents and my fellows kind of apprised of how to do it and getting kind of repped to doing it, right? So I do it for everybody. And I think it's more important when you have some inferior glenoid bone loss in addition to a large Hill Sachs lesion. But I really think there's so many subtle, it's not just the, oh, this is a large Hill Sachs lesion on MRI, it's the location of the Hill Sachs, the depth of it and the width of it. And so I think it's wise, especially when you're first starting to measure it on everybody, because there's something like, oh, there's no way that's off track. And sure enough, it is. And there's a lot of really subtle bone loss that you might not appreciate with an MRI, on the glenoid side especially, because the cuts are larger sometimes. And so you don't get that perfect circle as well as you can with a CT scan, but that's another subject for another day. But yes, I measure it for everyone. That's great. It's better to be prepared intraoperatively for potential bone block or augment procedures. So again, thank you so much for the comprehensive tour de force of sports medicine shoulder surgery. Truly impressive. Next on the agenda, we're gonna transition now to the live surgery with Dr. Nick Verma. He's our professor and director of division of sports medicine at Rush. He's also the head team doctor for the Chicago White Sox. He's going to perform a ladder J. Bryson, I hope you stay on for this. Oh, I'm sticking around. Excellent. Hi, Nick. I think Nick has a PowerPoint presentation that he's going to present initially, probably outlining some of the principles that he will employ on this cadaver. So we'll bring his screen up next. trained on here in the United States, and it does carry a higher complication rate when compared to arthroscopic surgery. So hopefully what we'll teach you today and throughout your fellowship is how to do this safely for your patients. It's important, as you already heard, one of the first steps in identifying patients who need a Laterge is quantifying bone loss. We do this by using a 3D CT scan. We subtract the humerus so that we get this on-face view. We know that the inferior 2 3rds of the glenoid can be modeled as a circle, and then we can use either a diameter-based or surface area-based measurement to determine the amount of bone loss that's present. And we've written our technique of how to measure in the Arthroscopy Technique Journal, and I'd look there for some more information. One of the tips that I've learned is that when you see this flat anterior glenoid rim, that tells you that you've already entered a critical bone loss situation with about 12 to 13% of bone loss present. So if you see the flat rim in the front, you know you should be thinking about a bone loss procedure. We've already heard about the hillsacks and the evolving concept of a engaging lesion. And the way I think about this is how those two lesions interact. And it's kind of like when your tire goes over the pothole. If your tire is larger than the pothole, you're not even gonna know it's there. But as that pothole gets bigger and bigger, which means that your glenoid is getting smaller and smaller, your tire may stay the same size, but now all of a sudden you fall right into that pothole. So learn how to manage and identify engaging lesions. This is my algorithm for deciding patients who need a Latergé procedure with bone loss. The first step is to look at the glenoid side. If they've got anywhere at or above a 15% glenoid defect, that in my mind is a patient that should be indicated for Latergé transfer, particularly if they're a young active individual. If they don't have a 15% defect, then we need to determine if they have a hillsacks lesion, is it engaging or not engaging? If it's not engaging, you can proceed directly to a Bankart procedure. If it's engaging, then we'd consider adding a Remplissage procedure. The anesthesia here, make sure these patients go to sleep. You need them relaxed and you need complete muscle relaxation from your anesthesiologist in order to make this procedure happen for you and to make sure that you get the retraction that you need. I generally use a general endotracheal anesthetic in combination with the scalene block. And we like to control the blood pressure keeping our systolic around 100. The beach chair position is preferred. I set them up about 20 degrees and we make sure to position the scapula appropriately as you'll see. Here's an example of an exam under anesthesia. To me, this is an intraoperative confirmation of an engaging lesion. So you can see in this patient, how I translate the shoulder and it essentially locks into an anterior translated position. That's an intraoperative confirmation of an engaging hillsacks lesion. Remember that unlike a total shoulder, you're not gonna be working on the face of the glenoid, you're gonna be working on the neck of the glenoid. So you really wanna position these patients so that they're sitting slightly off the edge of the table and we're gonna put a bump medial to the scapula. You want the scapula to fall away from you so you can get to the appropriate position on the neck and get your coracoid into the right spot as you see here. The neurovascular anatomy will show you but the biggest risk is the musculocutaneous nerve which lives anywhere between three to eight centimeters from the coracoid tip. So that's what you gotta be able to identify and protect during the surgical procedure. And we'll show you that intraoperatively. Most of us now do this through a subscapularis split. We know that most latergies are done in our young active population. And if you take down the subscap, you can see subsequent subscapularis muscle atrophy and potential dysfunction. And there probably is some advantage of coming over the top of the inferior half of the subscap to create a tenodesis type effect. Coracoid placement is critical. You can get the graph too high or too low. Generally what I like to do is to look at my preoperative CT scan and try to identify where do I need the graph to go in order to fill my defect. And this generally puts my first screw at about the 430 position. It's imperative that you get the graph flush to slightly recess to the glenoid. Just like any osteoarticular construct, if you get the graph proud, you're gonna see increased risk of contact pressure, contact stress and ultimately osteoarthritis. So the graph needs to be flush. If you do it properly, this is our experience from Rush. You can be successful with a relatively low complication rate. Ours over about 133 patients, 8% complications, fortunately only one neurovascular injury. And most of these were mild and resolved with non-operative treatment. Return to sport is extremely successful following Latergé with return to sport rates lifted in the literature anywhere between 70 to 90%. So it works well even in getting an athlete back to the field of play when the procedure is properly indicated. So from here, we're gonna move over to the cadaver specimen and we'll show you how to do it. Brian, let me know as we do this, if my hands get in the way and we'll try to reposition the camera. Can you hear me, Brian? We good? Nick, sorry, I was muted there for a moment. Okay, go ahead. I will provide some guidance. Right now you're in a good spot. Perfect. I think if we could get a higher angle of visualization, it might be helpful. That's better. So just some quick introductions. Joanna's holding the arm for us. She's with Science Care, who is our specimen provider. Kevin Parverish is one of our fellows this year who's just finishing up and headed to Orange County for greener pastures. And Jake is our rep from Smith & Nephew who's gonna help us with the Latergé set. So I've already started the dissection. You can see that we've aligned this left shoulder. Coracoid process is here. Inferior axillary fold is here. I've made the incision slightly larger than I normally would, but essentially you're gonna do a bikini strap type incision in order to expose the underlying deltopectoral interval. You've got a choice here in terms of what direction to take the vein, medially or laterally. As you know, there are more branches of the vein on the medial side. It's more interconnected to the deltoid, so most of us prefer to take it laterally. So you can avoid significant bleeding. And here's the deltopectoral interval that we've opened. The first retractor that we're gonna use is a Cobell retractor. So we're gonna place one limb underneath the pec, the second limb underneath the deltoid. And I'm gonna place a retractor over the top, which is gonna go just above the CA ligament and the rotator cuff. So now you can see that we've got the CA ligament right here. Can you see that? Yeah, we see it well, Nick. Good. So we've got strap muscles. We've identified the lateral border of the strap here. We've got coracoid process here. We've got CA ligament here. And the first step is to transect that CA ligament. Now there's some controversy about what you do with the CA ligament. I tend to leave about a centimeter of a stump, and this gives me the opportunity to potentially use the CA ligament for closure of my capsule later. There often are branches of the, or fibers of the coracohumeral ligament here, and I'll often use a bovie at this point just to go down to the base of the coracoid, which is gonna make my exposure and my release of the coracoid easier later. At this point, we now need to start working on the coracoid itself. So I'm gonna put my first retractor right over the top of the coracoid process. So that's gonna go here. So we've got conjoint tendon coming down, coracoid process, and coming off the medial side right here, you can see the pectoralis minor, and we've dissected in the split between the conjoint and the pectoralis. So I'm gonna take a knife. What do we do with it, guys? Nick, what words are you about the suprascapular nerve as you're doing that? So in this position, I'm really not, because the suprascapular nerve should be behind the coracohumeral ligaments, which will palpate in a second. It's probably more of an issue when you're putting your screws in place and you come through the backside, but here I think there's relatively little risk. Obviously, as you come more medially on the coracoid process, you're gonna get down into close proximity to the neurovascular bundle. So I do this with a bovie, and I'm basically staying directly on the medial border of the coracoid process. And then I'll use my finger to help dissect, as well as using a blunt device to help expose that. We're gonna come over the top here. Let's get the coracoid retractor. In this set, we've got a specific coracoid retractor. It looks like that. So it's got a little edge to it that allows you to go way down to the base of the coracoid and just retract the soft tissue out of the way. And then I'm gonna measure out my coracoid tip, which is right here. And I usually like to put a ruler on and just make sure that I've got at least 20 millimeters of coracoid available in order to make my osteotomy. So here's the tip here. 20 millimeters is gonna put me here. So I'm gonna need to move Kevin just a little bit more medial to make sure that I get enough room to do my osteotomy. Now, the second check is I'm gonna- Yeah, you're not taking too much bone. You do, you can. You can actually get into the articular surface. Remember, the base of the coracoid comes down to the articular surface. Or if you go way medial, you could potentially get into the base of the coracoid ligament. So you wanna be sure that you're at the right position. So the other thing I do, Brian, is I put my finger underneath and I can feel the elbow of the coracoid process. I put my finger over the top and I can feel the coracoid ligaments. And that helps me to set the level of my cut so that I don't get too medial. At this point, so here's our mark. I'm gonna come down so that we've got at least a 20 millimeter piece of coracoid and I'm gonna make my osteotomy. So we do that with a 90 degree saw, as you can see here, but in most cases, the saw is not long enough. So you've got to complete the osteotomy with an osteotome. So I'm gonna come right back into that same spot that I was before. And I'm just gonna come all the way through. And there you see the osteotomy is complete. So at this point, I'm gonna use a coker. And now you've got to release the coracohumeral ligament and all the soft tissue surrounding the coracoid itself in order to be able to free it up and mobilize. We talked about the muscutaneous nerve. You're really not gonna run into it here. It's gonna be much more distal. So we'll do this working on both sides, just bluntly freeing it up. Do you ever look for the nerve, Nick? I'm sorry, say that again. Do you ever look to identify the muscutaneous nerve? I usually do it just by dissection with my finger and hopefully we'll get a look at it here. Once I get down to this point, I just basically use my finger to push down and we've got a good look at the nerve here. Let's see the scissors. So hopefully you guys will be able to see this, but I'm gonna come right through here. This is just a fascial band and there it is. You see that? That's muscutaneous nerve. So you can see that we're probably about five centimeters distal to the tip of the acromion. And you can see how if I really put tension pulling this out of the wound, I can put a lot of tension on the nerve itself. So you don't usually see it that well, but you should at least palpate for it to make sure you know where it is. Now, if you look at the coracoid itself, you can see I'm all the way back to the elbow of the coracoid. So that tells me that I've taken just about as much bone as I possibly could. This is probably a little bit of a bigger spike than I would normally like to see, but that's the maximum bone that you can actually take. Do you guys have a ronger or no? Okay. So this is a coracoid holding device. Most of these sets have some type of a dice that allow you to hold the coracoid itself. So I'm just going to grip the coracoid process and I'm going to secure it here. Let me have that saw again, please. And the first thing I'm going to do is just flatten off this spike of bone that we have to make sure that I've got it. Oh, take that for me one sec. Kev, I'm going to hold this. I'm going to ask you to just saw for me, if you can. You can take that one out. Yeah, talk about how you're positioning that for a traditional latter J versus a congruent arc. If you- Yep, let's get this cut and then I'll show you that. That's a great question, Brian. So I'm trying not to squeeze too hard here because we've got cadaver bone. Go ahead. Good. So we're going to make that flat and I'm going to use, can you hold that for me, Kev? I'm going to just use a knife here to clean off the backside and then I'll show you the positioning. Let me have a pickup, please, guys. Got it. So normally in a real case, obviously, we would use that saw to decorticate the backside of the coracoid. If I do that now, the bone gets mushy and then it doesn't secure screws. But basically what Brian was saying was that the coracoid process normally sits like this. So in the normal, let's just get this re-gripped one more time, Kev. And just move your fingers. Good. And, hold on. Okay, try to secure that for me one more time. Good, we're going to try not to break our coracoid here. But in this situation, we prepared the coracoid for a standard position, which means that this is going to become the aperture that sits against the glenoid neck for healing. This lateral surface of the coracoid is going to become our articular surface. So we're going to put the coracoid essentially down like that on the glenoid. The second option is we turn it on its side such that this inferior surface becomes the surface that articulates with the glenoid. And this surface, the undersurface of the coracoid becomes the articular surface. You can see the advantage of doing that is I get a much wider piece of bone. The disadvantage is I get a much thinner piece of bone. So I'm going to transfer, I'm going to trade a bigger piece of bone for reconstruction for a larger lever arms on my screw and increased risk of fracture versus smaller width for bone reconstruction, but a much wider area of apposition and better security of my screws. I would say in general, I do almost all of my reconstructions using a standard position. And I honestly have never used the congruent arc, but it's certainly a reasonable way to do that as well. So the next step is to prepare our pilot holes and we've got a drill guide that allows us to do that. So I'm going to just flip that into place. You can see that this drill guys has some pre-prepared holes and I'll just make sure that I'm in the center of the coracoid process. Kevin's going to drill this for me. So I'm going to take a flat osteotome, put it right behind the coracoid process. The top hole and the middle hole is going to set us apart about 10 millimeters. Kevin, when you go through, just stop for a second. Go all the way through. And then it's important that I flip this on the side and I generally use a bogey to do this, but in this situation, I'm going to use a marking pen. Come on out. So I'm going to mark these holes so that when I have the coracoid in place, I can find them. Go do the other one. Nick, that's really nice and controlled. If you try to freehand it, it flips all over the place. Yeah, it does become a big pain in the butt. So here are my two holes on the backside of the coracoid itself. So hopefully we'll be able to find those. Now I'm going to flip this guide out of position again so that I can get back onto the axis. I'm going to measure two things. Number one is, remember, this coracoid is going to sit like this. So my inferior screw hole is going to be here. So I'm just going to measure the depth of that screw hole. So I'll come all the way through and I'll just measure that. What do we got, 12 usually? So we've got 12. And then the second thing I'm going to do is I'm going to take this offset guide, which allows me, this is going to become the articular edge. So I'm basically measuring the offset between my hole and the articular edge. And here we're at about between seven and an eight. I'm going to select a seven just to make sure that I've got this graft in a slightly recessed position. So those are the two measurements that I need. And now I'm done with my coracoid prep and I'm ready to move on to my glenoid exposure. So we'll slide this guide off. We're going to take this and stuff it back down into the wound. At this point, I'm going to move my cobell so that it starts to hold some of the chitlins out of the way. We're going to rotate the arm like this and let's take an Army-Navy, guys. Kevin, you're going to have to reach underneath if you don't mind. And we're going to come through here and we're going to just retract the pectoralis. So hopefully you guys can see this. Can you guys see? Nick, have you done your split yet or are you doing that now? I'm doing it right now. Okay, so here at the bottom is the inter-circumflex vessels. Here's the top, which is the rolled up border. Here's the lateral margin, which is the biceps. You can see the muscular fibers of the subscap itself. People often debate where to make this split. I like to make it at about the 50-yard line. I don't like to go too inferior because it makes my retraction superiorly more difficult. So remember, we need to identify the capsule. So we're going to come right into the muscle portion of the subscap itself and I'm going to start splitting the muscle. Let me have that 90-degree self-retainer. And I'm going to come through that split. Kevin, with your other hand, if you can, what I want you to do is also just sublux the humerus posteriorly because right now it's sitting up. Yeah, perfect. Okay, so we've got this retractor here that allows us to just open up that split. It's helpful to have either an arm holder or an assistant retract the arm back. And I'm going to come right through there. And now you can see that I can start to see the capsule underneath the subscap. And it's very easy to identify it as you go medially. So can you see the white of the capsule there? That's capsule right here. And I'm just going to split the subscap a little bit further laterally to be able to see what I need to see, okay? So now I've got my hand in. I can feel the glenoid margin is right about here. So I need to go a little bit more medial in order to get there. Kevin's going to sublux posteriorly. I'm going to pick up this capsule and I'm going to do my capsulotomy. And I can either do this in a vertical or a horizontal direction. Remember that you've got cartilage underneath so you just don't want to go through willy-nilly. But now you can get your first look into the joint. Can you guys see the humeral head there? It's a great feel. So the next step is we're going to put in our two critical retractors. The first is a Fukuda retractor. So this goes in through the split, if I can get it in. And across the glenoid, that's there. And the second is an anterior glenoid retractor. So it's a pitchfork type device. And this is going to go over the front, under the subscap, just leaving me that view of the capsule, if you can see it, right? So now we've got our first look at the glenoid underneath. I'm going to just split the capsule and the labrum. And I try to do this at about the 50-yard line. We're going to come all the way down. And then I'm going to just strip it off of the anterior rim or the anterior margin of the glenoid itself. I'm just elevating that. Nick, can you do a subperiosteal dissection there to stay away from an axillary nerve? That's what I'm doing. I'm trying to stay under the subscap and subperiosteal. I'm actually going to get Kevin in a little bit better position under the subscap. So I'm just going to take this. And I often use these to just elevate the subscap out of the way. Remember that you have that in there and that you're not going to leave it behind later, but that'll help to push the subscap out of the way. And now you can see, we're looking pretty much directly at the glenoid neck right here. Hopefully you guys can see that. I know it's a tough view. No, it is a great neck. We're just going to continue elevating. We do this with a bovie generally, and I'll put a tag stitch into this inferior capsule. I have it loaded up here. And that'll allow me to later repair the capsule if I need to. So I just want to make sure that I have control of it. So I'm just going to put a tag stitch right here and come over the top here. Nick, how do you decide whether to sew into the CA ligament stump versus put an anchor there? I generally put an anchor there. You know, as you know, Brian, there's a lot of controversy about do we close the capsule? Do we not close the capsule? Does it even matter? Do you make the graft inter-articular, extra-articular? I think the reality is it's dealer's choice. There are plenty of people that don't do anything with the capsule and report fairly favorable results. When you get done and you have that big graft in place, it often becomes difficult to actually get it in and get the capsule to cover the coracoid itself. So I try to basically take this capsule, put it back at about the four o'clock position, simply so I can correct any inferior components of instability, because I think that's one of the failure points of a Latter-J is they come out below the Latter-J itself. Okay, so now we've got our exposure along the medial margin of the glenoid neck, as you see here. Okay, if you're really struggling, you can actually put a pin up at the top, but I'm just gonna reposition our self-retainer to hopefully be able to see this a little bit better for you guys. So I'm gonna put this in and just spread it open, but you can put a guide pin just below the coracoid base where you made your osteotomy and use that to retract superiorly. So if you wanted, you could come lever up here and put a guide pin in place. I don't think we really need to do that. So the next step is we've got our offset guide. So remember, we already prepared our coracoid. We measured it. So we have this same offset guide. That's a seven. Can you switch it to an eight? That'll allow us to prepare our pilot hole in the same offset that we measured for our glenoid itself. So I'm just gonna come over and in. I'm gonna try to make sure you gotta pull way over, Kev. Sometimes it's helpful in this situation to, let's take this out for one second. If you're having trouble, particularly in these patients that are barrel-chested, we happen to have a cadaver that's like that. It can be very difficult to get your angle to get into the right position. So what you often need to do is to take out the core, the, hold on one second, the cobell retractor. And that just allows you to get just a little bit more retraction. And the other thing that you saw Kevin did do is he loosened up a little bit on the humeral side in order to better position that. So we've got this offset retractor now, and this is gonna lay right along the face of the glenoid. Hopefully you can see that. And if I do it correctly, if I put that guide along the face, I know that I have a 10 degree offset angle to the glenoid itself. So I'm not gonna penetrate the glenoid and I'm gonna prepare my first pilot hole. Now we didn't mention it, but we of course would have prepared the glenoid surface here to accept the graft. We can do that with a burr or the saw, but in this situation, obviously if we do that, we're gonna have no bone because of the cadaver. So now I'm gonna take this measurement and I'm measuring about, let's see where we are here. I'm gonna just go across. 24. Yeah, it's probably about 26. Yeah, maybe 26, 24. So we take our 12 millimeter graft plus our 24 millimeter prepared hole, and that'll give us a 36 millimeter screw. Okay, so now we fish our graft out of place. So we've got our two prepared pilot holes here. I'm gonna take my screw. I'm with this just a screw on a driver. Okay. Nick, most of your screws are 34 to 36 millimeters, right? Yeah, they are about, can you help me with that? Yeah. So the first thing I'm gonna do is, this is the hard part. Let me have something to hold this with. Jake, can you just hold that for me? Right here. Now those cannulated screws that you're- They are cannulated screws. You know, it's a great question, Brian, and it's a big discussion point about whether you should use cannulated screws or solid screws. And there's really not a lot of good literature to guide us. We've done a biomechanical study, as you know, at Rush, that shows that it doesn't really matter at time equals zero what you use. But, this is the hardest part. But I prefer one cannulated and one cortical. Can you see if you can get a better grip on that for me? Perfect. And let's see if we can just get this, once we get started, we'll be good. So I put this screw in, and I'm just gonna come out so the screw is just peeking through the backside of the coracoid. Tell me when, okay? Yeah. Good. So you can see that we've got this screw now that's just coming out through the backside of the coracoid. I'm gonna maybe put it in a couple more turns. And so what this system allows me to do is to basically drill the pilot holes in the coracoid and the glenoid independently, so I don't need to worry about trying to hold that coracoid in place. Now the hard part can be, how do I find that hole? And so what I do is I take the cannulated guide, I go down through the screw, and then I find the pilot hole. So I'm in through the pilot hole now, so I know that all I've gotta do is screw this in, and it's gonna guide itself down into place, and it's gonna take the graft in the appropriate position. So I've got the graft sitting into the coracoid itself, and I'm just starting to tension this first screw. And I'm gonna get it finger tight, but not over tighten it, because I need to be able to align it with the face of the glenoid itself. So I'm gonna come down here and just basically tighten it up but not over tighten so I can still rotate the coracoid. Do you have something to pull that pin with? Give me a coker or something. Nick, do you ever put a plate on there to distribute the compressive forces? I don't. You know, there have been some studies from Europe that have suggested that maybe that can help with our fixation, but I have not used it. I don't have any experience with it. So now you can see, Brian, that we've got it provisionally fixed, but I can rotate the coracoid back and forth. And so what I'm doing is I'm feeling the articular edge and feeling the cortical edge, and then making sure that I've got it lined up properly. I put this wire back in because that'll help to guide me in terms of the orientation in which I put my first screw in place. And then I'm gonna take my drill, and because I have that pre-prepared hole in the coracoid, I use that as my drill guide, and that's gonna help me to drill my second hole in the coracoid itself. So now I'm through. I'm gonna take the same size screw because I already measured and there shouldn't be a big difference between the two. So that's a solid screw, but you could use a cannulated if you were inclined. You could use a cannulated here, and I may just because it'll make it easier to get the screw in. Do you have the cannulated guide? Actually, I got it. I'm good. So this is our second screw going in. That looks great. It's about a millimeter recessed from- Yep, just slightly recessed. Okay, and now when you tighten these, you wanna alternate between the screws. Remember, the graft can be somewhat soft, so you certainly don't wanna fracture it. So I'm just gonna finger tighten on one side, just get it secured down, and then I'm gonna finger tighten the other side, just get it secured down. And I'm not gonna go crazy here because this cadaver bone is really soft, but you can see how that lines up the edge of the coracoid perfectly. Now, if I was concerned at all, I would take a burr and just machine this so that it would fit properly with the coracoid itself. So now we've got our graft secured, and potentially we could be done with the procedure, but if you want and you're interested in repairing the capsule, you can bring this capsular stitch back into place. We're gonna release, come, just release that for one second. We're gonna release this for one second because that's holding me up. Hey, Nick, it's Dougas. How are you, man? Do you ever use washers on those screws? Say that again? I do generally use washers. So here's the capsule that we had at the beginning. What I generally will do is to try to make this graft extra articular is, can I see your guide? I'll put one anchor just in between the screws on the native glenoid margin. So I'll come right up to the glenoid margin, come in between the screws, and I'll put one single all suture anchor just into that middle portion. And that's about a 430 position roughly? Yeah, that's probably reasonable. Maybe just above that, closer to three. Is that right, Jake? Yeah, okay, now. There you go. So this is just an all suture anchor. You can certainly use almost anything you want. It's double loaded. Pull that out, good. And I'm gonna just take one out for the purpose of time. Can I get that free needle? And I'll just take this capsule. And again, what I think is important here is to make sure that you correct this inferior component of instability. So I wanna make sure that this capsule is tensioned so that the inferior glenohumeral ligament is back into the right place. So I'll just pass this through as a simple suture. Hold this with the other hand, Kev. Kevin's gonna tension it. We're gonna bring it up and in about 30 degrees of rotation so that I don't over tension it. And then we'll tie this one suture. Now, the other thing that you could do is you can use sutures around the heads of the screws to act almost like a suture anchor on the Latter-Jay coracoid fragment itself. Or you can tie into the coracoid acromial ligament and I'll show you the stump there in a second. So there are a couple of different options. The final options, you can do nothing. You can just close at this point, leave the capsule alone. And there's actually been a couple of good studies recently published that shows that even if you do nothing in the capsule, you have a pretty good result. So what the capsule role here in this situation is hard to know. All right, so now we've got- This looks fantastic. Really, congratulations on a technically proficient and excellent procedure. This is well done. Thanks, buddy. So just the last point to make is here's our split in the subscap. You can let go of this. Here's the conjoint coming through the split. So we would just put two side-to-side sutures closing the subscap and the capsule, bringing the arm in about 30 degrees of rotation. And you can see how, as we bring the arm into abduction external rotation, that conjoint becomes a sling in the front of the shoulder that will help to secure the shoulder and prevent instability. Thank you, Nick. Again, this was exceptionally well done. I don't know if the audience realizes how hard it is to do an open cadaver surgery like this, but this is about as good as it gets. So lucky to have Nick and thank you so much for your expertise. Thanks, buddy. I appreciate it. Next, we have Dr. Jeffrey Adugis. We're going to play a demo of a previous UCL reconstruction that he's done. He's gonna moderate it live for us. Just given the COVID restrictions on travel, unfortunately, he couldn't make the trip. But nevertheless, his insights are a treat and I'm sure you're all gonna enjoy this. So we'll let this roll next. All right. Hey, everybody. Jeff Dugas here from Birmingham, Alabama. This is a UCL exposure and subsequent repair. So, our typical exposure is just posterior to the mid portion of the medial epicondyle. So, we'll typically make this incision about one-third above and two-thirds below the medial epicondyle. We really want to aim the distal part of the incision a little bit posterior. We don't want to go straight down the ulna. We want to go a little bit posterior. And so, we'll get through the subcutaneous tissues. We'll always look for the medial anabrachial cutaneous nerve, which I believe in this video, I don't think I took the time to find just out of the interest of time. But we will always look for that and it can be in a lot of different places. So, I would encourage you to do this dissection, you know, relatively meticulously. You can spread bluntly all this soft tissue over the medial epicondyle. But we found the, you know, medial anabrachial cutaneous nerve anywhere from a couple centimeters above to a couple centimeters below the medial epicondyle. So, you do have to kind of be careful doing this. I'm just gonna kind of blow through this stuff here just to get exposure. We want to expose the medial epicondyle completely. Our preference in our practice is to do a muscle elevating approach, which is why we approach the medial side of the elbow from a little bit from the backside. Also, we tend to do ulnar nerve transpositions in a lot of our procedures and I think that's kind of dealer's choice. I don't think there's any good reason not to. I've kind of gone back to with the repairs doing more and more of the ulnar nerve transpositions, whereas for a while I was not doing them. There's the medial anabrachial cutaneous nerve and you can see it's just kind of a little bit above the medial epicondyle there. So, I also need to say thanks to Steve Cohen. So, I cut it for the purpose of visualization here. Steve Cohen was my assistant on this case and I know his partner Mike Ciccotti is watching all this and Mike's a great friend and current president of AOSSM. I think you guys have already heard from Mike. So, it's amazing that the leadership continues to support the fellows and you guys are certainly in good company here. Mike's a great guy. So, anyway, so we expose the medial epicondyle. Like I said, we do ulnar nerve transpositions in most of ours. So, we do a little bit bigger exposure than the guys that do a muscle splitting approach because you don't obviously have to find the nerve. So, for the purpose of exposure, we made this dissection a little bit more proximal than distal. But here's the flexor pronator mass here. You can see the tendon, this big wide mass tissue. You can kind of see the tendon there. If you're going to do a muscle splitting approach, you want to be a little bit on the posterior side of that. Kind of posterior middle, I would say. If you're looking at the tendon, most of the time you're going to split it kind of 70-30. That way you still get a little bit of tendon to repair to. So, you're not just dealing with muscle fibers. So, if you're going to do a muscle split, this is how we split it. You're going to split it a couple of centimeters. I tend to say, you know, three to four centimeters. You want to be in the muscle. Next, we're going to split the muscle so that we can see and get down to the underlying ligament. So, we're going to make this a little bigger than we normally would just for the purpose of this dissection here. And Steve and I are going to kind of bluntly split these fibers. We're not trying to cut across these fibers. We're just trying to split them. So, I've got a hemostat there and you can see I'm just splitting these fibers. I don't want to cut them. These are all very valuable fibers, especially in a thrower. So, we're just going to split these things. You've got to obviously be careful of the ulnar nerve posteriorly here. This is the approach for the docking technique and for any kind of muscle split. And right underneath there is the ulnar collateral ligament. So, this is the anterior band of the ulnar collateral ligament. Right down there at the tip of the hemostat is where the sublime tubercle is. And obviously up proximal is the medial epicondyle. So, you've got a couple of centimeters there of medial collateral ligament. The next thing we're going to do is obviously we've got to see the ligament. So, we're going to split the ligament in its mid portion. So, we're going to go from the apex of the sublime tubercle. And I would tell you that if you're going to air here, the error you want to make is anterior. In the UCL, the worst thing you can do is air posterior. So, we're going to take the apex of the sublime tubercle right in the midline. And we're going to split the fibers of the ligament right up from the apex and go up towards the medial epicondyle. We want to be careful not to go posterior. We want to stay in the mid portion of the ligament. You go posterior, you're really into capsular tissue and you're not really splitting the ligament. So, we're going to split ligament all the way through it. Full thickness split all the way down into the joint. And that's going to expose the ulnar humeral joint, which you can see right there. It's important that you see this landmark because you have to know where the joint line is. And especially if you're going to drill tunnels near the joint line in the ulna, you need to know where the joint line is. So, I can take a freer or a hemostat or something. I need to know that I know exactly where the joint line is. So, we're going to finish that split. We always debride the undersurface of the ligament in terms of that capsular tissue, bursa, the stuff in the sulcus down there. That has a lot of nerve endings in it and we debride that stuff. If we were going to do a reconstruction, we would obviously drill our ulnar tunnels anterior and posterior to the apex of the sublime tubercle. If we're going to do a repair, we're going to start right at the apex and go right into it. So, we would create a curved tunnel if we were doing a reconstruction anterior and posterior right there where you can see I'm making those two marks. If we're going to do a repair, we're going to go right on the right on the center of that thing right there. We want to make sure we're aiming away from the joint with this if we're going to do the repair. In this case, we're going to drill tunnels for a reconstruction. So, this is the posterior portion of that tunnel. I've got a guide here we can use. So, we've got an angled guide that we can use to create these angled tunnels. This thing sits right over the apex of the sublime tubercle. This is a nice angled guide that helps create these tunnels and gives you a good aiming angle to connect them. So, I'm going to get a good connection there. It's obviously important to hold this in place as you drill the second tunnel. Otherwise, you'll lose the ability to connect them. In this case, I didn't think the drill was on there tight enough, so I had to redo it. So, we're going to put that back on there and find our hole again. Chuck let go of the drill, but you got to hold this thing in place to make sure you don't lose track of your of your preferred angle to get access to your... let the guide help you. So, we've got that. We don't want to go through the other cortex. I'm just kind of depth stopping one cortex. I'm going to hold that still while I drill the second tunnel. This is going to give us about a centimeter bridge. Obviously, if you break through that bridge, you don't have any fixation of your graft. So, the next thing we're going to do is take a curved curette and we're going to connect those two tunnels. So, we're going to take a number zero or number one curette and we're just going to connect those two tunnels together so that we get a continuous curve tunnel in the ulna. As I said, if we were doing the repair, we would have just drilled one single tunnel at the apex. Next, we're going to take a suture passer and this is something I'll bend in advance. So, I'll take a Houston suture passer and I'll just create a little kind of two-thirds of a bend on it with a needle driver or something like it. I just kind of bend it around the tip of my thumb and then I take that suture passer that I've bent and I feed it through the tunnel so that I can collect it through the other end of the tunnel. I can grab the... in this case, I needed to bend it a little more. So, we're going to get that thing to pass through there and that way we're going to be able to pass our graft through the tunnel. I will say that from a graft standpoint, we like to use the palmaris if it's present. If it's not present, we use the contralateral gracilis. There have been several studies on this. Obviously, the gracilis, the bigger tendon, more collagen. For those that have a tissue deficiency, I think it's very important to use a gracilis for more collagen. For those that have a normal amount of tissue, a palmaris is fine if they have one. And, you know, harvesting the palmaris is something you have to be obviously careful with and the technique of that is very important. If the graft is really big, if they have a really big tendon graft, you can use some mineral oil to guide it through the tunnels. So, now I've got the suture passer pass through the one tunnel and into the second. You can see it there. So, I can see it coming through the second tunnel and I'm just going to pull this loop through and then I can put either a loop suture or I can pull the graft through. So, we had taken a graft ahead of time and I think we took a graft or we used a suture for this demonstration. But, we're going to pass a something that will serve as our graft through this loop and pull it through the tunnel we just drilled. I would also caution you to wash these tunnels out with some irrigation. Heterotopic bone in these cases is a real problem and so you want to make sure you wash them out real good. So, in this case, we used a suture tape just to serve as our graft. So, now I've got my graft pass through the ulnar tunnel. Next thing we're going to do is go through the humeral tunnel. So, the humeral tunnel is drilled at the insertion or the origin of the ligament. It's important not to be medial to the native origin. You want to be right at or deep to the native origin. You do not want to be medial. You're out there too far on the medial side. It's okay to be a little bit deep to it, but I actually aim right in the middle of where we split it right up at the medial epicondyle. The other thing is you want to make sure that you're aiming into bone. So, this is a bit of real estate here that you have to be careful with. You don't want to end up posterior. You don't want to end up anterior. You certainly don't want to end up in the ulnar humeral joint. So, we're going to use a drill guide for this. Just a single drill guide is usually used. In this case, we didn't have the drill guide we normally did, so we're going to use the other portion of this Y guide or V guide that we use to drill the ulnar tunnel. So, we're going to put this in here. Again, we're going to try to be right at the apex of our split and aim up into the medial epicondyle. So, we want to be careful that we get it into bone. We don't want to be posterior. We don't want to be under the muscle. We don't want to be anterior. So, we're under the muscle of the flexor pronator mass. So, I can feel with my finger where the bone is. I want to make sure I'm in it. So, next thing we're going to do is we're going to enlarge that with a straight curette. So, we're going to make a little, we're going to enlarge that tunnel a little bit and then we're going to try to, if we're doing the docking technique, we're just going to drill our little dental drill. We're going to measure our graft and we're going to drill the dental drill off the anteromedial aspect of the medial epicondyle and pass it up there and tie it over the medial epicondyle. In the case like we do it, we do more of a figure of eight, the modified job. So, we're going to drill our tunnels in the medial epicondyle. So, we're going to drill this one that we already drilled and we're going to go all the way through it up to the top portion of the medial epicondyle. This is why we do ulnar nerve transpositions in most of these is because this drill tunnel here, if we make this drill tunnel, we're going to definitely have a chance of affecting the ulnar nerve. Now, doing the muscle split, we don't typically take the ulnar nerve. We don't typically transpose it. That's one of the benefits of the split is you don't have to really worry about the nerve in terms of proximal. Most people that are doing this are doing this for the modified job or the docking technique. We typically do the modified job technique. So, we're going to drill all the way through this. We would certainly have done an ulnar nerve transposition prior to this. So, we're going to drill all the way through. You can see we've kind of bottomed out the drill. So, I'm not going to get much further than that. So, I'm going to just have to take the drill by itself and hope I don't wrap up the muscle in the ulnar nerve again. But, we're going to go through the medial epicondyle up there. And again, it's important to aim away from the tip of the medial epicondyle. We don't want to be right on the medial tip. We want to give ourselves some real estate. So again, we're going to go with the straight curette. We'll find that with a hemostat and we'll make sure we take at least a centimeter. So, we're going to measure about a centimeter away from that tunnel and that's where we're going to start the Y portion of our tunnel and we're going to connect to the longer tunnel that we already made. So, this is going to be the Y portion of our medial epicondyle tunnel. And again, I'm going to use a drill guide because I have one. So, we're going to make this again leaving a centimeter. This is all about the bone bridge because we don't want to not have a bone bridge here. You could take a bovie if we had one and make a little mark there so you don't wrap up tissue. Obviously, in the cadaver lab we're not going to do that. But, I'm just going to connect this tunnel. So, this is drilling into the previous tunnel that we made from distal to proximal. So, now I've got a Y-shaped tunnel. Again, I would wash these out with some irrigation. I'm going to enlarge these with a curette so that I know that my graft can make the trip. If the graft is too big, it's not going to make the trip. So, I would tell you that that tunnel I drilled there because we got pushed a little bit by the tissue is probably a little bit more posterior than I would have liked it. But, I'm going to enlarge these. Then, I'm going to use the suture passer and I'm going to retrieve the graft from proximal to distal. So, now I'm going to take the suture passer and I'm going to go through both tunnels. The figure of eight is made by placing the posterior limb from the ulnar tunnel into the larger longitudinal tunnel and the anterior limb from the ulnar tunnel into the shorter Y-limb of the medial condyle tunnel. So, here we're going to take this and pull this up. That goes through the longer tunnel. And next, I'm going to take the suture passer and I'm going to pick up the anterior limb from the ulnar and put that into the Y, the shorter Y-tunnel. It's important here not to spear the graft with the passer. You don't want the graft to go through the graft. So, it's important to make sure we don't spear the graft or the suture tape in this case with our suture passer. If you're not sure you're through it, you can go back and take a curette and make another pass at it or you can go distal to proximal. So, we can always take a suture loop and do it that way. So, in this case, we weren't sure. So, we came back again and we made sure we got all the way through it. We could pull the graft back from the limb that went through if we needed to, if we were worried about it. In this case, because it's cadaver bone, I wasn't too worried about it. So, we can enlarge these things with larger and larger curettes depending on the size of the graft. And now we're going to see that we can get the, retrieve the loop from the tunnel down here. So, now I've got the loop coming through and I'm going to be able to pull the other limb through the shorter of the Y tunnel. So, now I've got my graft passed and I'm going to be able to tension this. So, we will always close up the split before we tension our graft. So, I would take a couple sutures and close up the split. The idea of a reconstruction is to augment the native ligament as is the repair. So, we're going to always close up that split. And then we're going to hold these sutures in place, hold the graft in place and tie it to itself. People talk about what angle to tension the graft at. When I'm doing reconstructions, I typically tension it at about 70 degrees of flexion. When I'm doing the repairs, I typically tension them at about 20 degrees of extension, of flexion. And so, I want to make sure that I do not over constrain the native ligament. So, the graft needs to be positioned in a way that it doesn't over constrain the ligament. This graft with this one here, this may be a little posterior on the medial pecondyle, which is not a good thing. Clinically, we would want to be a little bit more anterior, which is what I'm showing you there. The reason for that is if you tension this in more extension, when you flex the elbow up, the posterior position is going to keep you from flexing the elbow all the way up. So, we got to make sure that we have good positioning of our graft tunnels. And then we got to make sure also that we can flex and extend the elbow completely before we tie it down. So, we would take this graft and we would tie a couple of small knots in the graft above once we find our position and then sew it down. So, as you can see, I'm telling everybody live that I would rather have this graft a little bit more anterior. So, now we're going to do the internal brace. So, the internal brace is a little different. The internal brace, we're going to make our tunnel right at the apex. And I've seen people talk about doing both of these operations, doing a reconstruction with an internal brace and maybe just putting the internal brace tunnel a little bit more distal on the sublime tubercle. That can certainly be done. So, here we're going to drill our tunnel for the internal brace. That's a tunnel right at the apex of the sublime tubercle. Next, we'll take a tap and we'll tap this hole in order to accept the 3.5 millimeter swivel lock with the fiber tape and the super suture on it. So, the whole idea of the internal brace for this was born out of the idea that some of these things don't really need to be reconstructed, that some of the injuries we see are not severe enough to require that. I think we've been pretty true to that over seven years and that has borne out to be a reasonable option. I caution people that expanding the indications could be disastrous. And although the experience so far with revising these has not been difficult, I think the failure rate will go up if we expand the indications into, you know, poor tissue and tissue deficiency. So, that's where we would drill our medial epicondyle tunnel for the internal brace. I'm sorry, the sublime tubercle tunnel for the internal brace. Same tunnel for the internal brace on the medial epicondyle. So, we're going to elevate the tissue here off the distal side. So, we're going to create effectively a distal tear. So, if this was a distal tear and you're looking straight at the tear, this is what we would repair. So, we would use a suture from the internal brace to repair that back. And this is a pretty common scenario. So, there's our internal brace hole. And we would take a suture and we would repair that back from a suture that's in the islet of the internal brace anchor. And then we would put the internal brace tape over the sewn back and closed split in the ligament. Internal brace tape over the sewn back and closed split in the ligament. Again, I'd want to be a little bit more anterior with our tunnel. So, that's really the entire crux of UCL surgery. There are a lot of ways to skin this cat. There are multiple techniques that have been developed, hybrid techniques, allograft techniques, single position techniques rather than dual tunnels. There are all kinds of different things that have been shown to be very successful. And I think that a lot of these things can be used to successfully treat ulnar collateral ligament injuries. With that, I think that's about it. And I'm going to give it back. I'm going to give it back to Brian and take any questions that you guys might have. Brian. Jeff, thank you. That was fantastic. We learned a bag full of tricks and I feel like I could almost convince myself to do one next week. We've got time for one question, so I'm going to make it a loaded one. Sort of with the epidemic of overuse and throwing in younger athletes and earlier and earlier indications for UCL reconstructions in younger kids, how are you algorithmically treating them with internal braces versus reconstructions with autograft tissue? When you're dealing with a high school player versus a professional athlete, are you more or less inclined to use an internal brace versus a reconstruction and are biologics playing a role in that decision-making algorithm? That's a great question. I would say that it's less of an algorithm and more of an individualized decision. A lot of the main ingredients in that decision are seasonality. One of the things about the internal brace for this is the shorter recovery time. It's half, but at least six to seven months recovery versus 12 to 15 for a primary reconstruction. There's no doubt that people come in thinking they want the repair. Everybody that walks in thinks they want the repair. The problem with that is that not everybody fits the repair. People have bone in their ligament. They have enthesophytes that have to come off. They have bad tissue. They've got all kinds of things that don't fit what we try to accomplish with the internal brace. Now, I have patients that say, look, I want to pitch one more year of high school and I'm done. I don't have time for the reconstruction. Do the internal brace and if it doesn't work, it doesn't work. Okay, I've done a few of those and so far, knock on wood, that's been okay. But I think the idea of the internal brace is what we see when we cut into a lot of these ligaments is that the level of pathology is just not as bad as some. You see the blown in half ones. You see the gymnasts and the guys that pop their ligament off or they've been working on it for years and every summer they go down with an elbow injury for a couple of weeks and their tissue is crud and you know, all these kind of things. So those people, I don't think reconstructing them is a bad. I think reconstruction is the right idea for those people. Remember, UCL reconstruction is a great operation with a long history and Frank Jobe and Jim Andrews and others, Lou Yoakum, have taught us, you know, that this is a great operation and the UCL repair with internal brace is in no way meant to supersede that. But a lot of the people we see don't have injuries that necessitate more tissue or necessitate that kind of a recovery. I don't think it has anything to do with age, velocity, level of play. I've got guys throwing over 100 miles an hour with both. I've got guys at all levels thrown with both. I don't think that any of that stuff makes a difference. The one area that I will tell you that I think repair with internal brace has superseded reconstruction is in revisions. Revision UCL surgery is one of the worst operations any of us do that do UCL surgery. It's one of those things you never feel good about. It's not a gratifying operation. The success rate flat out sucks and so it's one of those things that it's at 50 or 60 percent success you just can never feel good about. Repair with internal brace is a better answer for revision than re-reconstruction. I think the more that we do these the more all of us that do these kind of operations feel that for revisions the repair with internal brace has really taken its place there. I think that there's more to come with this. Last year in the NCAA 25 percent of UCL surgeries were repairs with internal brace. That's up from like three or four percent just three or four years ago. So it's definitely finding its place even among the elite athletes. In fact this coming Saturday in Chicago one of my patients is going to come back from a revision that I did with internal brace and he's pitching against the Sox. So with bated breath I'm watching for my man to come out and throw the ball pretty well against the team that I'm one of the team docs for. So you know I love the Sox and I work with them but I'm really hoping that my man throws the ball well. So it's still in its infancy and there's a lot of room to grow. I hope that's that's a long answer to a great question. Well that's what we wanted and I hope he doesn't pitch too well. You know I'm still pulling for my socks and if I love this ever for the brace or with allograft do you ever add them to UCL's? Yeah I've added the brace for for reconstructions. I've never done any allografts for UCL's so that's a that's a thing I don't have any experience with. I know the results have been shown to be okay but in my hands I've never had somebody that I thought I wish I hadn't taken their own graft. So until I have somebody that I think gosh if only I hadn't harvested their own tendon I'd be okay. I'm going to keep harvesting their tendon. But I do think that there are some John Conway and George Paletta and some other guys are doing some really nice hybrid reconstructions with the internal brace. I think we'll see more of that as the numbers grow. You know we're starting to get a couple of revisions. Chris Ahmad revised one that I did and Chris and I had talked about it. I'm getting ready to revise another one that somebody did. So there haven't been a lot of revisions where people have torn through the tape. So far the results have been very gratifying and good. Well thank you again. I think that's all the time we have for this evening. We've had a wonderful broadcast. I've got to thank our corporate sponsors and supporters once again. Arthrex, Smith & Nephew, and Stryker. We couldn't do it without you. And thank you Latul and Volker also for all the support today. And I wish you all the best. Get a good night's sleep and tune in tomorrow same time. Okay and Volker will take the lead. Great job everybody. Thanks. It was awesome. Good night. Good night guys.

hand sports injuries

common elbow injuries

chronic tibia stress fracture

elite gymnast

surgical techniques

Latergé procedure

coracoid process osteotomy

ulnar collateral ligament

UCL reconstruction

extensor tendon injuries

scaphoid fractures

scapholunate ligament tears

intramedullary nailing

coracoid placement

graft mobilization