Thanks, Eric, and it's an honor to kick off this wonderful meeting, and what a collaboration. I'm really excited to be here to start this session and start the whole meeting. And we're going to talk about the good, the bad, and the ugly of decision-making and evidence-based literature in anterior shoulder instability. So these are my disclosures. None of them are really pertinent to this talk. So we'll start with the shoulder dislocation. It gets reduced in the emergency department. Now what? Well, if you look in the literature, you can support treating it nonoperatively, treating it arthroscopically, or treating it open. And there's literature to support all three. So how do we come to understand what's the best thing for each patient? Well, let's start with the good, okay? We have great clinical science due to many of you doing the hard work to do the research to help us understand the outcomes from our treatments. We can take that science and we can use it in decision analysis modeling, and we'll talk about that. And the thing that we need to get to more is shared decision-making through patient preference tools, and we'll talk a little bit about that, too. Well, this has been an adventure that started for me at West Point. And Jim Wheeler started by looking at, well, let's scope cadets and see what happens with them and compare them to nonoperative treatment, and he found that there was an improvement with just doing an arthroscopy. And Bob Arciero took it a step further and said, well, let's do transglenoid and see if we can compare the outcomes and found better outcomes with surgical treatment. I was fortunate enough to join this team, and along with Bob, we looked at prospectively what's the pathologic anatomy of a first-time dislocator, and we found that the Bankart lesion was the pathologic lesion that was associated with these traumatic first-time anterior dislocations. Well, from there, we had a reason. We could fix these high-risk instability cases and restore the anatomy. But we didn't have the evidence. And the hard work to get that evidence was done by people like Sandy Kirkley in Canada in a multicenter study, and Craig Battani in the military that showed reduced recurrence of instability and better patient-reported outcomes. So it's hard to believe this was 10 years ago, but we took a lot of that level 1, level 2 evidence and did decision analysis modeling with Chad Mather, who's an expert at this at Duke. And decision analysis modeling takes this great clinical science and allows us to come up with predictive outcomes for non-operative treatment, for operative treatment, for groups and for individuals. And based on the science at that time, we could take the demographics of an 18-year-old male and say, you're going to have a 70-point better outcome on your WOSI score, but probably more important for sharing with patients, your chances of having a stable shoulder 10 years is 83% versus 34% with non-operative treatment. Similarly, for an 18-year-old female, maybe not as big a discrepancy, but better outcomes for that person, and you can share that information with patients. We combined that with conjoint analysis to look at what are patient preferences, and then look at how that information and sharing that information and using some of these tools with patients can lead to better outcomes. And we found better outcomes, better decision making when we did that shared decision making as we educated the patients with these decision tools. So the information is out there, the decision tools are out there, and we can make it even better because you all are still doing that great clinical science. And since 2011, there's been multiple studies, and I'll just highlight a couple recent ones. You know, Michael Robinson in England has done a great job of looking at good clinical science and has shown that comparing a washout, an arthroscopic washout, to an arthroscopic bank heart, better outcomes in terms of recurrence rates and patient-reported outcomes if you do the repair compared to a washout. And then just this year, published in the American Journal of Sports Medicine, randomized clinical trial out of France, again, better patient-reported outcomes, lower recurrence rates with an arthroscopic bank heart repair versus non-operative treatment. And let's not forget about the open bank heart repair. You're going to hear more about this in a little bit from Mike Pignani and Bob Arciero. The open bank heart repair is a great operation, especially with the subscap split, lower recurrence rates, and this is not just for first time, but this is for recurrent instability as well. And this is a great multicenter study done by Nick Mattotti in Canada from 2014. So we can take that information and add that to our decision analysis modeling and share that information with our patients as we go through this shared decision-making process. Now how about the bad? What's the evidence show about bone loss? Well, again, at West Point, John Dickens and Brett Owens and the team there has carried on the tradition that Jim Wheeler and Bob Arciero started, and they've looked at this. With a first-time dislocation, half the patients will have significant clinical bone loss of greater than 5%. That's pretty important. And then with each dislocation, the bone loss increases, and the cadets that came into the academy with previous instability showed up with 10% bone loss on their admission MRIs, and all of them had recurrent instability. So there's increase in bone loss with each instability event, and that's something that you're going to hear more about from Steve Brockmeyer and others as this symposium continues. Now how about the ugly? Well, we've got great information, but we're not getting that information to our patients, and we're not getting the right treatment to each patient. So this is a study that we did looking at a database to see how many people with dislocations saw a provider that knew how to give them the information, an orthopedic surgeon or a sports medicine physician, and only 50% of those patients with a dislocation were seen within 30 days by somebody that could help them in that shared decision-making process. This is further complicated by the fact that when we looked at sports medicine-trained orthopedic surgeons and queried them on what the outcomes were, they were only right about 60% of the time. So combined with not getting the patients to the right providers and not having the right information, we're only getting the evidence to our patients about 30% of the time. We can do better, and we need to do better. It's our responsibility to do better. So for me, the future is bright because I know that we can do the right thing. We are the leaders in healthcare, and we can change it so that we get the patients to the right providers and we give them the information that the patients need to have. So we need to do the right thing so that we can take a, this is a scope of a first-time dislocator with a radial tear and an involuted labrum, and we can get that patient to the right provider so that technically they can do the right procedure to restore that anatomy. And the way we're going to do that is through information that you're going to get today. We need to know the literature. We can share that information with our patients, and we need to take the time and use the tools that are out there to do that, and then carry out the non-operative and the operative treatment with skill. And you're going to learn more about that the rest of the symposium. Thank you very much.

decision-making

evidence-based literature

anterior shoulder instability

clinical science

treatment options