Good evening. Thank you for joining us tonight for the AOSSM Fellows webinar, Complex Shoulder Cases with moderator and panelists, Drs. Patrick Smith, Alan Hirahara, Peter Millett, and Anthony Romeo. Dr. Smith is tonight's moderator and presenter. He practices at Columbia Orthopedic Group. He is co-director of sports medicine at the University of Missouri-Columbia and team physician at the University of Missouri. I will turn this over to Dr. Smith to begin and introduce the panelists. Thank you, Meredith. Welcome tonight for our webinar on complex shoulder cases. We're very fortunate to have a very distinguished faculty here with us tonight. Alan Hirahara from Sacramento is here, and he's going to talk about a supracapsular reconstruction case later on. Peter Millett from the Steadman Clinic at Vail is going to talk about an acromionic vicar joint dislocation case. And then Tony Romeo, who's from Elmhurst, Illinois, is going to talk to us about the role of Latter-day Procedures. I'm Pat Smith again from the University of Missouri, and I'm going to start out first. But if you have questions, please submit them to the app and we'll answer those as they come up. So first I'm going to start out with a case of a shoulder. And this particular case was a pitcher who struggled with his dominant right shoulder. He had pain to the point that he ended up failing comprehensive conservative treatment and actually quit playing baseball. He was a college pitcher at the time. Came to be about a year and a half after he had stopped pitching because he was struggling even to play golf. So I talked to him when he was pitching, he had problems primarily because he lost velocity and control, especially in the acceleration phase. And again, he was having trouble with golf. He also had some pain at night and described posterior pain, had no history of instability or a dead arm type syndrome. Exam, tender at the greater tuberosity, you can see his numbers here, his forward flexion was fine overhead, no scapula distributed near winging. Rotation was good, but a bit weak, extra notation, had no pain, but some weakness, but good motion. Impingement tests were negative, cuff strength, a bit weak with the supraspinatus when I stressed him in the champagne position, infraspinatus and subscap were fine. O'Brien's maneuver, minimally positive and he was stable on load and shift. These are his x-rays, pretty unremarkable. I think everybody in the panel would agree, don't really see anything worrisome on his plain films. Here's a couple of selected cuts from his MRI. You know, always with these throwers, you worry about the superior labrum and that actually looks pretty good with this contrast study. Looking here, a little bit suspicious of his rotator cuff, he's got a little bit of a signal here more than I would like to see. You can see a sagittal and actually views look okay, except again, this little bit of outpouching here with the supraspinatus was a bit concerning. So my discussion with him revolved around, he looked to have at least a partial cuff tear. It failed conservative treatment and so I discussed with him the potential for surgical intervention for arthroscopy dealing with his pathology and you can see the labrum here looks fine. So here's a surgery video, you can see this is biceps anchor, looks fine, biceps tendon is fine, anterior labrum looks good, inferior labrum is fine, posterior labrum is fine. So here's his rotator cuff, looks a little suspicious. So I came in here and debrided this, going to stop this for a second. Tony, what are you thinking about this cuff as you look at this now? Let me run this a little bit more, after I debrided it. Yeah, so as you said, it is a little concerning and when we think about the ultra structure of the cuff, there's really five layers. And so that first layer, the capsular layer, that's definitely been damaged and the second layer is when you have those longitudinal fibers, but you can see it actually goes, there's a couple of areas where it goes even deeper. So these are the ones that are very concerning, but we know in our overhead athletes that despite that concern, the vast majority of the time, we're going to debride it and see how they do. We're not going to do a repair because actually surgical repair of rotator cuffs doesn't have a great track record. So I'm very nervous about this, but at the same time, I'm not sure there's another treatment that has value that I would do differently. Well, I'm with you, I'm just always debride them, always. So I did that and then I came in, I marked it with a spinal needle, so I could look at up on the bursal side, I thought, okay, we should be okay, and then I got up on top and look at this, I pushed my probe through, you can see the delamination, the tearing. So I liked it to fix it and so this is for a bone marrow aspirate, I'm going to use some stem cells. I actually took the cuff down, I've never done this before, it's a 19 year old kid, but this thing just fell completely wide open. So now I got to fix it, Peter, what are you thinking at this point? Anything in particular? Well, I think when you have a cuff that's that structurally deficient, that taking it down and repairing it is the appropriate thing to do. I mean, he obviously, he wasn't playing baseball at the time, so this is a treatment that I think it would be very effective for him to remove the degenerative tissue and then repair it. My preference is for a double row linked repair, anatomically restoring the footprint back down onto the tuberosity. I think you make a great point, even though he wasn't playing baseball, he was having night pain, again, he was having trouble playing golf, so it was affecting his everyday life. I did just what you suggested, the only thing I did is I added here a couple of demineralized bone matrix patches that I soaked in bone marrow concentrate, hoping to maybe get a little bit better healing for the repair. Let me jump this ahead a little bit. So here we opened it up, as we looked in, you can see the articular cartilage marge immediately. I like to debride right to the edge and put these anchors right on the edge of the articular surface. So I put two medial anchors in with tapes. The only difference is these anchors have a knotless mechanism with extra sutures, which allowed me to pull my patches down. So that's the difference here. I just thought, young kid, I'd add biology to it with these patches. So two anchors, and then both again have that knotless mechanism. You know, really important for the fellows, make sure your passes are three millimeters from the muscle tendon junction. So these are the two patches I just pulled down with those knotless mechanisms. That's DBM, soaked in bone marrow concentrate, and then I do my typical lateral row to finish. So the patches are pulled to the footprint, hoping that I would help stimulate a little better healing of this clearly degenerative tissue. So there's our final repair. So just kind of going through a little literature here, and Tony, you were on this paper, just kind of what you said, you know, non-operative treatment is generally indicated for partial cuff tears. Keep them up throwing, get them on a good rehab program, cuff strengthening, takes a couple of months. Operative treatment only for those that fail that, either debridement, mostly repair. And unlike when we talk about maybe older patients fixing cuffs, so they're 50% partial thickness. The recommendation in these stores is more deeper tears, more partial than say 75%. Our scopic approach is better than open. Return to sport in your article here, this review was 75% or better, but same injury level was only 50% with partial thickness tears. So again, these are very troublesome. A little interesting study published a couple of years ago, looking at 3T findings and pictures that were drafted. Professional baseball, you can see the amount of abnormalities they had on these MRIs, including partial cuff tears at 32% already, just heading to the major leagues. This was a systematic review published a couple of years ago, a little bit older age group averaged 42, mean follow-up three years. Return to sport was about 85%, only about 66% equivalent level of play. But for the highly competitive professional athletes that return to the same level is about 50% again. So we're kind of seeing a bit of a theme here. And then Peter, you were on this paper looking at, was there a difference after cuff repair, return to sport between recreational and competitive athletes? 15 studies, 500 shoulders, 347 identified as athletes. So the return to play was about 70%, pretty equivalent for competitive and recreational, a little bit different. You guys looked at a subset of baseball and softball had about 80% return to sport, but only 38% same level. So this is the concern is that even when you fix these athletes and do a cuff repair, the chances of them coming back to the same level are limited. So I think, you know, in this case, I was kind of stuck, bad cuff, debridement wasn't going to work. But again, that's really one of the few that I've ever had to take down an athlete. So the literature will tell us they don't do that well, Tony, any other thoughts that you have in terms of, you know, can we do better with these surgical treatments in any way? Well, I think that if you summarize it nicely, can we do better? I hope we can. I think the theme that you mentioned somewhere around 50% return back to the same level is fairly consistent in many different studies that have been done, and some even lower, as Peter mentioned in this series that they reviewed. So I think we can do better. We have to do better. And I think it is along the lines that you're exploring with using some additional biologics enhancement of the repair to see if we can make this better, especially in a young person. You know, if they're in their 60s and 70s and they have a degenerative tear, you know, the horse may be out of the barn, there's not much we can do, but in a young person like this, it seems to me that if we could figure out a way to get the matrix of the rotator cuff to heal and restore itself, we should be able to get better results than we're currently able to achieve at this time. Alan, do you have any other thoughts? You know, you take care of that minor league team in Sacramento, you see throwers a lot. Any thoughts on dealing with these bad partial cuff tears? Yeah, my big thing for this is I think absolutely for you, this was a no brainer that you did. I think the great, honestly, perfect thing for this. The only thing I would add to it is that I think doing insight to repair with like postage bridge using percutaneous techniques and with the new knotless technology and going with smaller anchors, I think we're going to get a better outcome because we can use the smaller anchors, not really interrupt that bony area, and then we can follow the margin of the actual attachment of the cuff. So as it comes posterior to the infraspinatus, I think one of the biggest problems people have is that they medialize that attachment inappropriately, and you need to follow the normal anatomic attachment, which has a small bare spot posteriorly. In that area, if you do that, you will have less problems with stiffness, less problems with abduction extra rotation, because if you close that area down, that's when a big part of the stiffness comes into play, and medialization of the tendon too. So I think as we get better, as you said, by augmenting with these grafts, by also using the percutaneous techniques, by using these ideas of smaller anchors as well, and then eventually with potentially even dermal allograft on top of it, as other potential thickening agents to get that tissue to kind of become more robust, as Tony said appropriately, I think we're going to get a much better outcome on these patients down the road. Great. Well, a great discussion. Thanks guys. Let's go ahead and switch to Peter's case is up next. Great. Can you guys see my screen? Yes. Yes. Okay. Let me just see here. I can't see it now. So hold on one second. All right. So I'm going to talk about AC dislocations. I can't see you guys. Peter, we can see your screen. If you're good like that, we're good. So these are my disclosures are also on the Academy website. We know that the goals of management of AC injuries are appropriate and timely treatment. We want to permit our patients to return to sports work and life as quickly and safely as possible. And we want to restore the pre-injury level of performance, as we just talked about in the last case. And I have a UConn football player, and that's kudos to Gus Mazzocca and the guys at UConn. And Tony's done a lot of work with them as well, looking at the anatomy of the AC joint, really helping us to understand this. We all know the Rockwood classification, grades one through, types one through six. And then the ISCOS modification with types threes being divided into three A's, which are stable, where they don't override the acromion, and three B's, which are unstable with overriding of the clavicle on the basmania view. And there's some thought that these may result in persistent dysfunction of the shoulder. Our management options, typically ones and twos, we would manage non-operatively. Most grade threes are managed non-operatively, although it's still somewhat controversial, perhaps for the type three B's. Operative is for the three B's, fours, fives, and sixes. And then we have non-anatomic reconstructions, such as the Weaver done, and now more anatomic reconstructions, which seem to have better outcomes, although slightly different complications. Non-operative management, are there any consequences? Well, you can have persistent deformity. You can have scapular problems. You can have loss of time if you need a surgery subsequently in an athlete. Sometimes there's associated injuries, such as significant labral tears. Return to play might be difficult in an overhead athlete, and performance issues for workers. We looked at this in a series of 41 patients who were initially treated non-operatively. Of these 29 patients completed non-operative management and seemed to do well, 10 patients in the group failed and subsequently required surgical intervention. And we didn't find that those who crossed over did worse in the outcomes at the ultimate endpoint. And we did find that, however, the patients who presented later tended to have a little bit worse outcomes, and they had an increased risk of failure of non-operative treatment. So I think for a month or so, it's worthwhile treating these patients non-operatively and see how they do. And then if they fail that, we can convert them to surgery. The indications for acute surgery would be clinically relevant associated injuries, such as a slap tear, a cuff tear, maybe an avulsion fracture, type 4, 5, or 6 injuries. If it's a type 3 that you can't reduce passively, sometimes they will buttonhole through, and perhaps overhead athletes, although quarterbacks seem to do pretty well with non-operative treatment. The options we have for acute fixation would be some type of fixation with fixation devices, anchors, primary repair or Bosworth screw, or some type of a reconstruction with a weaver done or its variation or anatomic reconstruction, which has now become more of the standard of care. So here's a case example. This is a 47-year-old gentleman who's working as a development officer and he's pushed while playing soccer, very active. He landed on his right shoulder. He enjoys snowboarding, soccer, and tennis. He's tender to palpation over his AC joint. He has limited range of motion, secondary to pain, and he has superior displacement of the clavicle on the X-ray. Here you can see that the X-ray on the AP view, you can see the side-to-side difference. Maybe I'll ask Tony, any comments on your imaging series for an acute AC dislocation? I think the one point that you brought up that the international community wanted to emphasize is that these views are helpful, but if you're very concerned about a type three being more worrisome, you see scapular dyskinesis, then the best mania view or proving to yourself that the clavicle overrides the acromion would be probably one more radiograph that you'd like to get to understand the severity of the injury and the potential for this to fail non-operative management. Yeah. One thing I noticed on the axillary view is that this is, you see that it's dislocated slightly posteriorly. I don't know if, does that influence your decision-making at all? You know, a lot of times on the radiographic studies, it tells me that when the patient's positioned to take that axillary view, that there's a lot of mobility, horizontal instability between the clavicle and the scapula. So again, this makes me concerned that maybe I'll get a vast mania view and see what's going on here, because probably when he stands upright, it will reduce in the horizontal plane, but then of course you have the vertical displacement. So again, I think it's another indicator that there could be a more severe problem. It didn't look like it was stuck in that position, but of course, if it was stuck in that position, fixed in that position, yes, that would be a concern. That would be a motion-limiting position for the clavicle to stay in. Yeah. When I tried to reduce it passively by elevating the arm, it was passively irreducible too. So it was kind of stuck there, which I think in my experience, those patients don't do so well with non-surgical treatment. Pat, do you have any experience with that? Yeah. I just agree with Tony about the Alexander view. We call it the Alexander view. Just pulling that arm across their chest and getting that lateral view, because it does look like it's posterior on that axillary view you pointed out. So I agree. This is worrisome. That one that you probably want to think about fixing, I would think. Right. So we talked about operative treatment and non-operative treatment. He elected to have it fixed. This is the positioning we use. I like a beach chair position with a C-arm. Here you can see it's not easily passively reducible. After we... Sometimes it buttonholes through the capsule. This is the glenohumeral joint visualizing the joint. There's no labral tear. We make our accessory enter superior portal. And in this case, we'll look for associated injuries. Maybe I'll ask Alan, if you saw a significant slap tear or cuff tear in association with this, what would you do? Actually, I'd just go ahead and fix them. And I talked to the patients ahead of time about that. I do think that it's important to fix those associated pathologies, because I find that later on, they end up being symptomatic if we don't. Okay. He doesn't have any other really associated injuries. So you'll see here the technique that I use. This is exposing the coracoid process here. Using a 70 degree scope in a transarticular position, you can see the coracoid and the conjoint tendon just over the subscap. We'll come in with an accessory enter inferior portal so that we can have access to the inferior portion of the coracoid. And then we'll come with an eight millimeter cannula from anterior inferior so that we can use that to help shuttle our graft. Then now we've placed a 70 degree scope and you can really see the anterior portion of the scapula. And we'll come in medial to where we're going to pass our graft. We'll make an incision superiorly. Since this is an acute injury, I usually will do just CC fixation and a CC reconstruction as opposed to an additional AC reconstruction. Here you see the drill guide going in for drilling through the clavicle and down into the base of the coracoid. And then we'll put our first, I like to just put a pin in so that I can make sure I'm right in the center of the coracoid. We can use fluoro to help validate that, that we're in the center and then we'll pass our cannulated drill and we can pass a suture through. At this point, I'll then use CC fixation with a button and two suture tapes. The button goes on the inferior aspect of the coracoid and then another button will go on the superior aspect. Then we'll make tunnels so that we can pass a graft. In Europe, sometimes they'll just use two CC fixation devices. I like to pass a graft as well. So you get some biology there to rebuild the ligaments. We use typically a seven millimeter graft and we pass a suture tape with it. Here comes the graft coming around the coracoid. It goes from posterior on the clavicle around the coracoid to anterior on the clavicle and then we have that suture tape with it. At this point, we can then use that suture tape as a tensioning device. Here we come in with a tensioner so we can actually reduce the clavicle using the tensioning device under fluoroscopy. You can see that we get it reduced perfectly and then we can secure our fixation, secure the graft and secure the CC fixation with a button on the top. So this is the button going on the top, a cortical fixation button on the top of the clavicle fixing those two cortical buttons and then we'll fix the graft by securing it to itself and then securing it with a figure of eight. Then we tie the capsule over the top and here you can see the final reduction. Here's some post-operative x-rays demonstrating this. Any comments on technique modifications that you guys have found helpful? I actually like using the guide that they have to pass the wires built past my graft. So I'm actually able to make a much smaller incision on the clavicle and then I can go percutaneously using that guide to get down to it. So I'm less worried about going down into an area I shouldn't be. Great. Peter, I noticed. Go ahead, Pat. Yeah, I noticed one thing that I've learned in doing these many, many different ways. We used to use wires from the coracoid to the clavicle and all kinds of different implants and a lot of things that didn't work so well, but I've always found that they tend to ride up. So I do what you do. If you look at your post-op x-ray, you slightly over reduced it compared to the other side. If you look at the CC distance, I think that's very important for the fellows to know. I always over reduce it and it always ends up coming back at six, eight weeks and looks anatomic, which is kind of hard to explain where the laxity, where the creep in the system is because you got strong sutures holding you with the two buttons. You've got a graft in, but they always seem to come up. So I do what you do. I slightly over reduce it and then it ends up looking good at the three months follow-up x-ray. So I think, you know, if you look at that film, you do pull it down to the coracoid and I think that's the right thing to do. Yeah. Occasionally they will pop up. So I tell the patients loss of reduction is probably the biggest complication that we see with these. Since I've gone to the smaller holes, 2.4 millimeter drill hole, I've not had any fractures. There are some cases I've had some myself where if you use larger drill holes in the clavicle or the coracoid, you can get fractures as well. And the pearls I'll share with the fellows just use a 70 degree scope from a posterior portal that helps to visualize the, the undersurface of the coracoid gives you a little more room. You can look from the front as well. If you need to, if you just can't get this adequate view, make your anterior portal, the accessory one a little bit more inferior and lateral so that you can get underneath the coracoid and then avoid disturbing the soft tissue distal to the tip of the coracoid. I do excise the distal clavicle if the patient has arthritis or if the joint doesn't passively reduce intraoperatively and I use this soft tissue dilator, the cannula dilators to create a space for the allograft before passage around the clavicle and the coracoid. We looked at our results, 102 patients, grade three through five dislocations that were fixed using these techniques. Our postoperative ASES score is 97, SANE scores of 94 and quick dash went down to two. So very good results with this. Loss of reduction was the most common complication. We had a few that had irritation because they had no soft tissue over this button. So sometimes you can get some soft tissue irritation as well. So that's something else to look out for. But the technique I think is improving. It's not perfect but it's improving and what I've learned is that certainly AC joint injuries can lead to significant shoulder dysfunction. I try and fix early the types 3B that are overlapping a lot, type 4 which are posterior and type 5 which are greater than 300% or buttonhole through. I like to do it arthroscopically because I can preserve the deltoid. I feel like I can actually visualize around the coracoid better. What I do know is that you need some type of CC reconstruction and fixation. If you try reconstruction only, it won't be strong enough. So you need some type of internal brace or cortical fixation device to hold it in place. As I mentioned, my preference for distal clavicle excision is only if it's irreducible or arthritic. The distal clavicle does provide some stability to the end of the clavicle. So we like to preserve that. And then I also do an associated reconstruction of the AC ligaments or the capsule for those that are high grade or chronic cases where it can sometimes pivot around the CC ligaments. So maybe I'll open it up to the group. Maybe I can ask Tony any pearls that you might have on that as well. Peter, I think you covered it very well. I think that when you treat these more acutely, I agree with you that you can either rely on the AC joint sort of soft tissue healing or even add some simple stitches there if the capsule is preserved well enough to be able to do that. I think when we have these chronic grade fives that are pretty severely displaced and there's not much of a healing environment that I have sort of bought into Gus Mazzocca and yours idea that we and the Europeans that we really need to do something at the AC joint too. So in that case, I'm adding essentially somewhat of an internal brace. I wouldn't call it an internal brace entirely because I really like to do essentially a figure of eight between the clavicle and the acromion to hold that together. Dr. Mazzocca has a complex way to use a dermal graft and to really restrict rotational motion which may be valuable. I think it's a little too complex and a little too much. And so I don't hesitate to use that additional fixation on the AC joint if I need to. And the other thing is when you look at the European literature, even in the acute fixation except for maybe our German colleagues, when they added a graft, the results were better. But interestingly in the acute, like the French still had a palmaris graft. It doesn't have to be a semi-teninosis, but they had just a little collagen. It's enough to kind of kick it over into the category of being better. So I would just keep in mind that just like with other ligaments, there's a lot of intraligamentous damage that's done and we can't entirely rely on that. It seems to get away with it in the acute setting, but I wouldn't hesitate to add some collagen for these injuries because they actually do pretty well clinically, but radiographically unless we do these extra steps, we get a fair amount of ones that just don't look so great. I remember Dr. Andrews always saying that if you want to be happy about your AC joints, just don't take x-rays after surgery and you'll be happy with the results. So if we really want to work on the radiographic reduction and what I think is the best function, I think you need to use the principles that you just presented. Thanks. Tom, what's your approach with an acute injury and an in-season athlete? For me, you know, I try to get them by. I've gone away from steroid injections. I've been more using PRP actually for pain relief and to get them through the season. It actually works pretty well. My question to you though, as I was going to ask that question, what's your percentage in your practice of the chronic grade threes, are you treated conservatively that you come back and operate on? The ones, you know, is that, what, could you give us a rough number of how many fail that conservative treatment? Is it 10%, 40%? Well, we had about- Is it dominance, maybe weightlifting guys, what's your thoughts there? In that one series, we had about a little over 40 patients and I think 10 of them converted to surgical. So if you, it's interesting, if you offered surgery to everybody on day one, they probably all would want to go for it because they come in with this deformity and it's painful and they think it must be, it needs to be fixed. But if you wait a couple of weeks, usually it'll settle down. And only in our series, only about a quarter of the patients ended up electing to fail that and elected to cross over and have surgery. So it's challenging because sometimes you have to tell them they're going to be okay and then they don't believe you, but it settles down pretty quickly within a week or two. I think that's important for the fellows listening to know that too. You know, Gus did that study where he did a longitudinal study of all the patients that came into the UConn with grade threes and they tried to be very careful with a true diagnosis and it was a little bit less than 20% ended up having surgery. So it was kind of along the same numbers. Interestingly, those people that had surgery did get better than their pre-surgical status, but that overall patient population was essentially the same results as the ones that did well with the non-operative treatment. And so in other words, if they failed non-operative treatment because they weren't doing well and you treated them, they went back to the non-operative level, but they didn't necessarily go back to, you know, day one before the injury. So you improve them. So I think it, as Peter said, I think it's quite reasonable for someone that has good scapular control, their pain goes away relatively quickly to treat their grade threes conservatively and see how they do. Because I think we have some pretty good techniques now on that type of injury where we can do an excellent job, even on a chronic basis, using some collagen and the fixation that Peter mentioned. Okay. Well Tony, let's go ahead and present your case next if we can. Sure. Thanks for your comments, guys. Great work, Peter. So I'm just going to bring up the subject with regard. So first of all, to all the fellows, congratulations. You're on the homestretch and I hope all of you have found a great job and we'll have a great opportunity to follow through what you would like to do. So I wish you the very best in the upcoming years. My disclosures are updated regularly at the American Academy of Orthopedic Surgery website as are all the speakers so that you have that information available. Here's our patient. He's a 17-year-old male and he was a football player and running back and he ran, he went to try to get a couple more yards and he sort of described this mechanism of injury that we see in rugby a little bit more on. He reached out and landed, people tackled him and he felt the shoulder come out of place. And so he dislocated his shoulder. It was put back in place. And you know, you would think like with most people in your head, you're saying, I know what happened. He tore the anterior inferior labrum. Most of the time this occurs, it's primarily a soft tissue problem alone. And in many patients, we can actually consider the possibility of treating them nonoperatively. But now there's again, as it seems to ebb and flow, an increased interest in treating these patients operatively because of the concerns of the complications that can have to happen. But about 80% or more of the time you're really radiographically and otherwise it's a soft tissue injury. And the question is, what do we do? Well, this kid was a little different. He wasn't even entirely skeleton mature yet. And you can see he kind of knocked off that rim of his glenoid. And so he went and sought some advice. And the advice he was given is that, well, you know, I think you should have a fixed and I think we could do it arthroscopically. And there was one physician that says, you know, this is a bigger problem. You have a bony problem. You're a 17-year-old. I think you should have an operation where you put bone there. And the family and the kid were like, no, there's no way I'm doing that. I don't want to do that. The MRI was obtained. We will get an MRI in some of these cases, but oftentimes when we're concerned about a bone problem, it's more of a 3D CT scan, which gives us truly the idea of what's the watershed that we have to start thinking about a soft tissue versus a bony operation. MRI is getting better and better. And if you get a 3T MRI, really well controlled, 2 millimeter or 1.5 millimeter cuts, you can see the amount of bone loss, but you have to have the right imaging size. But those are, you know, the next three to five years, I honestly believe that MRI will replace a CT scan in terms of our imaging choice because of the clarity of the soft tissue that we can all see so well, as well as what we'll be able to see on the bony injuries. If the kid was going to have surgery, you all know what would be done, right? It's the United States. So more than 95% of the time, it's gonna be some type of soft tissue operation, most likely arthroscopically, because that's what everybody does. And hardly anyone would consider a bone block technique in the United States. And the question is, are the indications for a bone reconstruction less than 5%? In our country, it seems to be, but around the rest of the world, particularly to take care of an athletic population, that's not the case. And the question is, are we really getting the results we're looking for? Are we really that good arthroscopically? So we've done a lot arthroscopically to make these operations work. And if you just look at a standard repair here, we can clear this up very nicely. We can then go and we can make sure that we have a really nice preparation of the glenoids. We'll just move ahead. And the key to the glenoid preparation, as you all know, is you need to make sure that bone is exposed and that's elevated off so you see the fibers of the subscapularis. So that tissue, when you leave that in place, it will float up into the right position. And so you get a nice solid repair. So we feel like we're getting a really solid anatomic repair. And then we've learned how to use devices that are much easier to put in. And we don't have to tie knots, which is not that we can't tie knots. We did that for many years and we do it very well. But it's just more efficient. And we're actually better at really tensioning things now that we've learned how to use these knotless fixation. There's a variety of different devices that are available to do this, but it really helps us in terms of doing this operation effectively and efficiently. And there's even some newer devices that are even without an anchor. And you can see this type of device here where you can go in and see, put this in place. And it doesn't even have an anchor in place. It's just a soft tissue. And again, a variety of different devices available. And when we're all done with these techniques, we really can go all the way around the shoulder. And if we need to, even around the six o'clock position on the right shoulder, or even the seven o'clock position, if we have to reinforce it. And we've become very confident that this is the right way to repair these things and we're gonna be successful no matter what. And we've really learned to think about this not as a 90 degree problem on a right shoulder from three o'clock to six o'clock, but really more like 180 degrees. We don't have to do it every time, but we wanna think about that and make sure we do the right thing. And we've learned how to reach all the different parts of the shoulder, including that back corner if we have to. This has really helped for posterior instability too. But even in anterior stability, we see some problems. Here's a guy that came to me as an NFL football player, and his problem was entirely posterior instability. Every time he tried to come up, his shoulder felt like it was slipping out the back. But you can see his anterior shoulder is not any better either. And so we've learned the techniques and hopefully in your fellowship, you've been able to learn how to do 360 degree lateral repairs so you can take care of the problem as it lies. His cuff was good, a nice secure surgical repair, and he's back to his sport. And again, many of us have moved on to an atlas to really make this fixation. So principle wise, three anchors below three o'clock on our right shoulder, and then add as you go, less than 20% bone loss. And we talked about lateral cubitus because we wanna make sure you address the inferior component. You can do that in the beach chair position too if you're a skilled surgeon. So we just wanna keep that in mind. And so those are the principles. So here's the kid's x-rays. The thought was, you know what? I don't wanna have a bony procedure. But the question is at 17 years old, football, wrestling, snowboarding, should he have had a bony procedure? What is the risk of recurrence in some of these sports? Well, for rugby and teenagers, the risk of recurrence for a bank or repair is over 85%. That's not a very successful operation when you have a 50% success rate based on the European literature. And that's why if you play rugby, you get a bony procedure if you have this problem. Well, this kid had this type of injury. Again, it was relatively mild, not too much bone loss, except there was this chip off the front edge and he had a fixation with four anchors across the rim. There was some thought about augmentation in the back, but they didn't do that. He went through the proper rehabilitation and around six, seven months, he was told, you know what? You can go back and play. And nine months after his surgery while wrestling, this happened, not good. But that was expected after the kind of things that this kid did, right? Well, I know a lot of people don't, but the failure rate in this patient population, 17 years old, is much higher than most people expect. And the fact is, is that most of the studies in the United States are no more than two years. When you go to the European studies at five years, the recurrence rate is more than double what you see at two years. So I think that really should be thinking about when a lateral J is the right thing to do. So now he's reduced and what do you do? You can see there's something like right with the front rim and you get the MRI study and what has he done? The anchor has been put in place. There was four anchors and essentially posted stamp fractured off that front rim. Now, what do you do? Do we go back and re-repair it? This is an example of what we might see on a CT scan in a similar athlete with this problem. Do we repair that? I think, you know, this is this kid at this time and you go in there and you see the failure of the previous repair. And with this type of fixation and this guy, here's your arthroscopic evaluation. You really have no choice. If you're gonna do another soft tissue repair in this setting, it's gonna fail. So the question is from the very beginning, why should we not do a lateral J from the very beginning? When is too much bone loss in the place? And I know everybody's pushing the envelope arthroscopically. Here's an example where you have to get very nervous about it. We know from our military population that that number is somewhere below 15% and above 10% in a high risk patient population. And so that's important. How much is that? It's not very much. And the fact is if they keep coming out, it becomes very much a significant increase in bone loss when they start coming out three, four, five, six times. So when you put them back on the field and you let them play and they keep coming out, you've now converted them over and still yet most of those people get an arthroscopic repair and your failure rate is gonna be much higher than it should be. So that's not the right answer. We're really only talking about between four and six millimeters of bone loss on a lot of these kids. It's not a lot. And that's why we use a 3D CT scan to really try to analyze that. And I'm sure many of you have heard of the on-track, off-track, this plays in a very important role when a Hill Sachs lesion's involved. And I didn't talk about it in this young kid. He didn't really have much of a Hill Sachs lesion. It was very small, a 10% or so. It was more of a scuffing of the cartilage, which we frequently see. But make sure you understand this principle. We actually have our radiologists giving us this number now because they've learned how to measure it for us and they helped us out with our studies. But if it's on-track, that means when the arm goes into the provocative position that the bone and the cartilage of the humerus will stay within the confines of the glenoid. If it's off-track, that won't happen. So here we are with this glenoid rim fracture. Pat, you would have probably fixed this kid early, arthroscopically. What are you gonna do now? Well, Tony, I think at this point, he's obviously failed the arthroscopic. He's got this bone involvement. For me personally, I would do a bone block case and I would do a ladder J at this point for him. Oh, sorry, go ahead, Pat. Yeah, just with his activity level. And as you said, he doesn't have a big heel sac, so his joint's in good shape. And I think overall, if his head's in good condition, his prognosis is really good, I think, with a well-done ladder J to stabilize him. And I think you'd do very well with that procedure. Acutely, would I have done it the first time with it? Probably not. I'd probably fall into, honestly, what you described. I probably would have done the arthroscopic. I probably would have done a little different. I probably would have done something post-human inferiorly. I would have done that with the initial. I do that in all the young kids. It's kind of like you said, these young shoulder patients with failures are much like what we see in ACL surgery. Our young adolescents tend to tear grafts and it's just a different level of activity that we're understanding. But I probably would now go ladder J, but I probably would have done him the first time arthroscopic, but I would have added a post-human inferior advancement of the posterior band of the inferior bone. Right, I can hear, yeah. Peter, what are your indications for, you have a ton of snowboarders out there and some of your extreme sports. When are you gonna say, you know what, maybe this is a borderline, but we're gonna do a ladder J because I know for sure your shoulder won't come out again? Well, I don't do too many. I do a lot of ladder Js, but most of them are revisions like this case. I would be a significant, I worry about wrestlers. I think wrestlers are challenging, but wrestlers a lot of times don't want a scar on their shoulder either because their opponent then is gonna see that scar and goes after that shoulder. So I've had them say, can you do it arthroscopically? Cause I don't want them to see that. So I don't know, it's definitely a tough case. I probably would have done the same thing that was done in this case. Maybe I would have been convinced to do a ladder J primarily. My indication is obviously a failed bank cart. Primary with a significant bony erosion of the glenoid. Maybe as someone with a failed pancapsular shift with hyperlaxity with unidirectional anterior instability, I might do a ladder J. But the vast majority are patients with glenoid bone erosion and contact athletes. Yeah, Alan, what is your thoughts? Would you ever do a primary ladder J? You think where arthroscopic skills put us in the ballpark to pretty much manage everything at least first time through? Yeah, I actually agree with all what the guy said completely. I admit I would have fallen into this and I would have done that but I do exactly what Pat just said. I do put in the inferior, I go posterior, check to see if it needs to be shifted up a bit. Cause I agree. I'm more remplissage although I know he didn't need it and I wouldn't have offered it for him but I do a lot more remplissages than ladder Js by far. But I do have to have that discussion about potential loss of range of motion with remplissage, of course. But overall, I agree that a ladder J for this, no question, at least at this point for sure. Yeah, so the one thing I would add is the one place where I might consider a ladder J is if the consequence of them dislocating is so overwhelming that they can't re-dislocate. So like a junior in high school that has one season to prove themselves. A professional person who's trying to get to the Olympics, an athlete who's renegotiating their contract next year where re-dislocation is gonna be so consequential for them. Sometimes rock climbers, extreme kayakers, things like that where the consequence of them coming out is so severe. I will have a lower threshold for doing a ladder J in those patients. And Peter, for the audience, he mentioned some people that have to have a real good range of motion. And the mythology of this operation is that you severely restrict range of motion as part of the impact of creating stability. And that in fact, doesn't have to be the case. Done properly, patients with the ladder J can have fairly remarkable range of motion and participate in sports very well. Obviously throwing a baseball is not the same thing, but very challenging sports like Peter mentioned, like rock climbing, windsurfing, above the head type activities they can do without a problem. And everyone's talking about making sure that the whole inferior hammock of the inferior glenohumeral ligaments resolved. And where these usually have a problem is in fact, the upper one or two anchors, sometimes everything's secure, it's everything below. And they actually, I think what happens is that there's this weak link as everyone has already mentioned that posterior inferior quadrant. And so when they go out, they kind of break down at the bottom. And so I think we do a much better job by putting anchors down past the six o'clock position. So that's a good point by everybody. This kid of course was a perfect candidate, I believe for a ladder J procedure. I do this through an open subscapular splitting approach. I don't do these arthroscopically. I'm sure some of you in the audience will be doing them arthroscopically in the near future. I think it's a very clever operation to do arthroscopically and I have done that, but quite honestly, I'm just faster and consistently do a better job doing it through an open approach. And it's a relatively small incision. As Peter said, about 70 to 75% of our cases are all revision cases. And the ones that are not revision or primary case are people that have been recurrent instability patients with typically greater than 15 to 20% bone loss. My other indications of course, is a high level rugby player would never do a soft tissue operation on them. They're gonna fail if they're playing at that level. And I do take into consideration high level snowboarders. I think that's a tough sport. Our motocross athletes, believe it or not, I think that's a pretty tough sport and I will do what I can to keep their shoulders stable and this works best for me. And we get these really incredible reconstructions in place. And this is what this kid's ladder J looked like. Nice solid reconstruction, screws in the right position, lined up perfectly with the joint. And in fact, he wanted to go back and try to play his last two games of football a little over four months after his ladder J. And so I did what we do for our high level rugby players. I got a CT scan, the bone graft was healed. His range of motion was about 90 to 95% normal. I let him go back and play his last two games of his senior season, which of course, as you can imagine, really was a great thrill for him and his family to be able to have that opportunity. So the one thing about the ladder J, if you get bone to bone healing, it's a faster recovery, faster return to sport than most of our CIF tissue repairs. Some final notes on this, people have been worried about the complications. Again, I think the complication rate is very acceptable considering more than 50% of our cases are done in patients that had prior surgery, but this is what people are worried about. So if you look at the 16 year old lady who failed an arthroscopic banker repair, so the surgeon did a ladder J procedure, but there's nothing about a ladder J that says that the screws should be in the joint. It wasn't a failure of the ladder J procedure, okay? It was a failure of getting the proper done procedure technically right. And this is 16 years old. And when you look inside that joint at 16 years old, I mean, that just takes your breath away. And you're like, oh my God, that's just horrible. I never ever want that to happen to me. And that's why I think a lot of people don't want to do the ladder J. There's tools, there's instruments, and there's devices to make sure that you avoid this problem, because this is a seriously devastating problem. For this young lady, I cleared everything out. I did a distal tibial allograft revision. I just saw her back four years after her surgery. And she has almost a relatively full range of motion and no pain. And her graft has healed well. And I hope that her cartilage has restored her glenoid side, but I couldn't do anything for her humeral side. And maybe I gave her a little bit more time with her shoulder longterm. So keep this in mind when we start getting around 13%, especially in our younger patient population. Consider a bone procedure, especially high risk athletes, rugby players, snowboarders, rock climbers, people that rely on this, a roofer that has to have a stable shoulder, or he might actually have a fatal event. That's very important. Otherwise, most people do an arthroscopic repair. And Alan brought up very appropriately the REM plissage. When do we do this? There's a nice paper done by the Rush Group. And again, if there's glenoid bone loss less than 15%, and yet there's still an engaging heel sacs, that's probably the perfect indication for the REM plissage operation. But a lot of people like Alan are having if they fix the glenoid side effectively, and there is a 15% or more on the humeral side, they'll do the REM plissage and feel this stabilizes the shoulder well. And there's some good evidence of that too. So for me, when I think about what I did a few years ago, you know, I'm primarily using knotless anchors, some soft anchors. I'm very aggressive with first time dislocators. If it's 50% bone loss, I tell them, you should have your shoulder fixed. You don't, you can do what you want, but you should have your shoulder fixed. And I would do the calculation on and off track. I think that's important to understand. I do use REM plissage, but probably a lot less than Alan. Maybe I should use it more. And I'll think about that. And then I just, I really, really moved away from revision arthroscopic bank or repairs. Because quite honestly, 15 years ago, we thought we were really pushing the envelope. We were just doing it a little bit better than the rest of the community. And that's probably arrogant, but that's kind of what we felt. I don't feel that way anymore. I think most people learn how to do a pretty decent arthroscopic bank or repair. So when it fails, I usually think there's something else going on and the bone loss is a big issue. And more and more often, I'll go straight to Latergé and I'm very happy with that decision. So I hope that's helpful when you think about the patients that you're gonna be taking care of. And it's, you're on your own without being able to look behind you and say, now what should we do? You're gonna be making those decisions and I hope that that will help you with some of those. So thank you for the opportunity to share that with you. But Tony, real quick, before you move on, you showed the distal tibia as your kind of savior at the end. Is there any indication to go distal tibia instead of Latergé primarily? You know, Alan, I think from a conceptual point of view, it's a great idea because the distal tibia has three to four millimeters of articular cartilage. There's a bit of a controversy out there. There are two or three different companies providing the distal tibia. Some companies are providing what they call flash frozen. So they said it's frozen in place and so the articular cartilage is still viable, but actually the study suggests it's probably less than 20%, maybe even less 10% versus the fresh grafts, which is what I typically use. And they typically, the cartilage is alive. And we know that because we've done some of these cases where we've gone back three or four years later where the rest of the joints become arthritic and the only cartilage remaining is on their distal tibial allograft. So we know that it can survive. And the cost of those two things that people are, you know, this is $4,500 to $6,000 per case and that's where you get stuck. This graft on our patients doesn't cost a penny when we do a Latergé and it works pretty well. But to pay that $4,500 to $6,000, that's one issue that we have to keep in mind since these operations are being done in ambulatory surgery centers and the insurance companies don't wanna pay that extra cost. The second thing is that there may be some theoretical value to the sling, but as we've seen primarily from our German surgeons and our Austrian surgeons, a bone graft that restores the glenoid, repairing the soft tissue or the labrum around it works just as effectively as a Latergé for recurrent instability. So I think, Alan, if the price comes down a little bit, it would be really great to modify this operation and to do it essentially arthroscopically assisted with a fresh distal tibial allograft. So we do an osteochondral reconstruction of the glenoid rim and that theoretically may preserve the joint over a longer period of time. Great stuff, Tony. All right, Alan, you wanna do your case here with your SCR? Sure, jump in. All right. Oops, sorry. My apologies. You can start on the actual first slide. Okay. So my disclosures as the others. So the history on this is a 59-year-old female. She's right-hand dominant. She's had two previous attempted cuff repairs, 2006 and 2013, having persistent pain, weakness, minimal endurance strength. In fact, the biggest problem is that she's a teacher and she can no longer ride on the board. So she's gonna be forced to retire because of her disability, which she really doesn't wanna do. In terms of her examination, passively, she's full, but actively, she can't get really above 90 at all. Anything below 90, she's good. The MR shows a recurrent tear of supra and actually part of the infra as well. And here are her MRIs. You can see there's really not much there. And then I'll show you the arthroscopic view of where she is. And this is what she's got. And this is what I'm looking at. So I'm gonna throw it back to you guys. These were my options. And maybe you guys have a few more that can add in. Debridement, biceps tenotomy, partial repair, lat dorsi transfer, interposition patch, bridging grafting, versocomial reconstruction, lower trap transfer, thalagraft, reverse shoulder arthroplasty, and SCR. So I'll just kind of throw it back to you guys. What do you guys think at this point? Is there anything I'm missing here? Alan, I didn't see the option of an overhead projector on there. So she didn't have to raise up her arm to right. You're right. You're absolutely right about it. I'm just kidding. Sorry. That's a good point. I think the bone loss is a big problem. We saw that, to be honest with you, we saw that 10 years ago and it seemed to go away. I don't know exactly why, but it seemed to go away. I'm assuming it's the types of anchors that are being used and things like that. But I haven't seen those kind of, we actually wrote a paper about that. In fact, Shane Noh wrote it for me during his fellowship year to tell you how long ago that was. And we saw it, not infrequently, but I haven't seen that type of bone loss in a long time. So that's pretty remarkable. And I think that's a problem. How are you going to get anything to heal to that area? Good point. And I'll show you, I actually hid this slide of what I did with those holes, but I'll actually show you in a minute. So anyone else have anything else to add? Cause I mean, at this point you might guess what I did. I did an SCR and this was a configuration I used. So I used three anchors on the glenoid. I used four anchors on the tuberosity. I used two side-to-side margin convergence sutures, two anterior, two posterior. And basically it's a three millimeter allograft, dermal allograft is what I used. And this is her surgery. So this is how we started. And this is how we ended. So I basically was able to do a full SCR for her. And from the undersurface, this is what you can see from the undersurface. So there's the glenoid. Yes, I keep the labrum and I go medial to the labrum in terms of my fixation. Now I'm going to just now pull up this slide here to show you, Tony, what I did. So what I did was I first saw these holes and first after some choice words, had to think about what I was going to do. So I did was at first I put in a 625 rescue anchor into the hole to see if it would just fit, see if it would hold. And surprisingly it did. And I was like, okay, but I wasn't confident just as you said in that. So I actually took some bio-dissolving cement called Kwikset and I was able to insert it into the hole and fill the hole. And actually it went really well. And it did so well, I said, well, let's do it on the other side. So I filled the entire hole with that cement. And then what I did was I then put in the anchor over it like that. And then the anchor went in. So that's how I ended up fixing this in terms of to that bone loss bone. And I actually do have the MRI to show you after the fact of what things look like. And it was very interesting how this went. Here's a five-year follow-up outcome. And actually she's currently at seven years doing quite well. And the interesting fact about this is that she never retired. She went back to work and is actually still working today. And this was seven years ago. And so that video was made at five years. And then here are her numbers from pre-op for ASES, VAS, acromiohemal distance, graph thickness measured on ultrasound from pre-op two years and five years. So 98, zero, 7.4 and four at five years. We do have plans to have her come back to get us some final numbers now that were seven. X-rays, you can see that we have a progression of two months, three years and five years post-op. And she didn't advance any arthritic changes at all. She did quite nicely. And her MRI, very importantly at five years, her graft is doing very well, no problems. And what's interesting in the two year actual image, what you'll see is you'll see the actual anchor still there. And what was super interesting is that that cement filled in very nicely in the articulation between the bone cement and the anchor was very, very good. And I was kind of stunned at that. So the ultrasound at five years was a four millimeter thickness of the graft still intact very nicely. The dermal out graft being shown there over the hemorrhoid. And then we did publish the two year SCR outcomes back in 2017 that we were finding. And they basically mirrored Mahada's numbers exactly. They're almost dead exact. What's interesting is that if you look at the SCR outcomes and look at all the papers, Mahada, myself, Denard Painton, we actually had some pretty good numbers, pretty low on the failure rate end. But then there are those couple of papers that followed right after us that looked at their failure rates and their failure rates were like 36 and 65%, which were crazy. And we're like, okay, well, why are they doing so poorly? Well, the Brass Group kind of published their data. And that was kind of the first indication that what was going on here? Because people said, well, wait, 45% completed healing. But then of course they had small numbers of people come back for MRI and their considered success rate was higher. But we learned something from them. We learned that one, they used on several cases, one and two millimeter dermal out grafts and they all failed. So you can't use small out grafts. We learned that they had done some Hamada three and four DGM changes, which did poorly as well. And so again, as I had said way back in 2013, we really cannot do these for arthritic shoulders. This is for loss of cuff. And of course we've had poor patient compliance for MRIs. And then there's a huge learning curve. And that's kind of the key, that we really have to learn how to tension it well. Don't over tension, don't under tension. Because if you over tension, it's going to rip out. If you under tension, it doesn't work at all. And this is a stabilizer. And that's kind of the thing. And so the paper that Lee put out, well, it turned out that they found exactly that, that graft type, graft thickness, and repairing to the posterior aspect, doing posterior margin convergence were critical. They were only doing single row fixation. And so absolutely they were ripping out and not having good outcomes because they were having failures. And the Woodmass paper, the problem with them is they had six surgeons that only did 34 patients. And they found a failure rate of 77% among surgeons first 10 cases. So there's a huge, huge learning curve here. And there's a lot of technical aspects to getting the fixation just right and the tension just right. But if you do it right, you really can get excellent reversal of pseudoparalysis with excellent fixation. And what's interesting is I heard a lot of people telling me that this is dead tissue. It's never going to work. It's going to just dissolve. And that's just not true. That if you use the proper graft, we showed in our paper in AGSM, that actually it was arthroscopy, arthroscopy, that number one, the graft thickens. So after tuberosity, it starts off at three millimeters, but basically after about one year, it's like four plus millimeters thick. And we also found that it vascularizes. So we were finding in the first 12 months, we'd see these pulsatile vessels within the graft, which went away eventually because it would transform into capillary flow. And you'd see the normal perivascular, normal vascular on top of the actual graft itself. And so this was becoming a relatively normal condition. So we've proven that these grafts can heal, but the end result is that fixation is important, but tension is more important. And if you're going to use a thick, thick graft like Mahatma on six to nine millimeters, the tension doesn't matter as much because you're putting in the spacer. But if you're going to use a three millimeter graft like we are, you've got to have the tension right because then it's truly a stabilizer. And what's interesting is at this point for us, we used to say they're for only irreparable, supra and or infraspace tears. But now we're finding with these massive cuff tears that we didn't have great outcomes on previously that were repairable, but the outcomes were poor and the chance of retear was high. We're finding that if we do an SCR and then a repair on top of that, we get a much, much better outcome. And what's interesting is that my numbers in terms of results, outcomes, and failures is so much dramatically improved because I now have options of what I'm going to do that's going to result in a better selection of choice of surgery that's applied to the right case to get a better outcome. So of course we look at failed conservative management, intolerable shoulder pain, subjectively unacceptable dysfunction, minimal glenemia or arthritis, but we really want to avoid arthropathy, bone defects, loss of musculature that's right there or shoulder stiffness. And currently we're kind of limited to about four centimeters anterior posterior distance sizes. And so that's kind of where we are. What do you guys think in terms of what you're finding for your massive irreparable tears? Hey, Alan, can I jump in real quick? We did have a question from one of the fellows in the audience for everybody. Do you guys have any indications for the subacromial balloon spacer for irreparable cuff tears? That was a question one of the fellows asked. Yeah, so the balloon, I'm not a fan of. I've talked to a lot of my friends in Europe who've used it and basically that dissolves and goes away within six months. And so as a temporary fix, sure, you get short-term good outcomes, but realistically you're not gonna have a good long-term outcome. And so it's gonna go away in six months. And if you haven't strengthened, you're gonna be back where you started. So I can't in good consciousness recommend that at this point. I don't personally have any experience with the balloon. So I can't really speak to that. I don't have any experience either. Nor do I. I wanna say one thing, Alan, great job covering some of the really critical points. But I wanna say something sort of from the fellowship director side of the fellows. And that is that this is a hard operation. These guys can make it look easy. Don't try to do this by yourself in your first six to 12 months of practice. I'm telling you, you may think you're really good, you're gonna be humbled. And the best thing that you can do is if you're in a good practice with some senior members or one of your colleagues is a year or two ahead of you or your same year, say, listen, I got some really tough cases that I would like to have someone in the room with me that's thinking like I'm thinking or helping me out. Can we like pick a day, a month or whatever where we put these hard cases on and you guys work together on it. Then it's possible. If you've ever tried to do one of these operations with someone who doesn't know what they're doing, it's a complete pain, it's a different operation. You have to do everything. It's hard, they can't hold the scope for you. You do not wanna go in there with a surgical assistant from the local company that's provided by your hospital for that day. So it's a tricky operation. Alan makes it look very, very smooth. Peter makes it look very smooth. You see his videos and it can be that way. But from a fellowship point of view, I'm telling you, don't be too egotistical to call on one of your colleagues or one of your senior members to say, can we do some of these tough cases together? Your training doesn't end in July, it just begins. And you'll be surprised how much better you'll be a couple of years from now. And you're gonna wonder what the heck did I do a couple of years ago? And you're doing everything your best, your ability. But I think the worst part of the educational process of our profession is the day you finish your fellowship in the next three to five years. We are not doing a good enough job helping people in that category. We have to do a better job. And I'm just giving you the advice. One of the things is stick together, work together, call on your senior mentors. You can do these cases if you have the right help. If you have no help, you're gonna be miserable and you're gonna think I'm not good enough, I can't do it. It's not the case. You need more practice just like we all did and we still do. And I'm just making that suggestion from the perspective of you guys will be out there on your own pretty soon and be humble, but continue to be brave and work with your partners and your peers and you'll be able to get this stuff done and be able to make it look like Alan does. But I think Tony, even one step further, don't be afraid to call one of us. We're your colleagues, we're here for you. I get a ton of people that call all the time. In fact, in about an hour, I have to get on a call from a guy from Australia to help him out. You know, reach out and come visit or go to labs and practice. I mean, there's just so much that is accessible now in terms of education. And with, honestly, the global community and the outreach that people have and the goodwill, I mean, we're here for you. So please, you know, make use of us. All good advice. Well, I think we're a little bit over our time. I want to thank the esteemed speakers tonight for great instruction and education and hope the fellows learned something good today. Thank you very much. Thanks everyone. Thanks, Pat, for organizing it. Thank you, Pat. Thank you, AOSSM. Good luck, guys. Thank you, Drs. Hirahara, Millett, Romeo, and Smith. Thank you, Meredith. The AOSSM would like to remind the current Sports Medicine Fellows about candidate membership. If you have not already, you may apply online for free candidate membership by clicking on the Membership tab at sportsmed.org. Register today for the AOSSM-ANA Combined Annual Meeting taking place on July 7th through 11th in Nashville. For more online and on-demand education and resources, visit the online AOSSM Playbook and Surgical Video Library at sportsmed.org, Playbook. And we will see you next month on June 8th. Thank you for participating. Good night.

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