Now, for questions, if you want to use the app, we do have a couple of questions in already. I'd like to start off with a question for Dr. Rauch. Again, what is the clinical relevance of your paper? Do you recommend slap repair versus biceps tenodesis in an instability population? Then also another question about the implications of your study for micro instability, potentially in GERD and slap lesions and overhead throwers. So I think this biomechanical study alone is not something where I would change clinical practice. So I think there's plenty of times where the biceps tenodesis or tenotomy is still indicated. However, it's more applicable to the significant school of thought of people that solely view the biceps tendon as a pain generator. So I think it sheds some light on, maybe there's a possible role as far as posterior instability. But again, as a biomechanical study, I don't think it changes my clinical practice at this point as far as management of true tenosynovitis, unstable slap tears. And for your second question about doing slap repairs and the instability picture, again, I think there's a lot of literature out there that shows particularly as patients get older, they don't do as well with slap repairs. And so I think I still would consider doing biceps tenodesis in those cases, but yes, in the younger patients with a slap tear and some element of posterior instability, I would consider doing a slap repair in that case. Along those lines, Ryan, I guess I would ask, when we do total shoulders and we think about the arthritic shoulder and the potential implications of instability, 98% of shoulder arthritis patients undergoing total shoulder arthroplasty still have their biceps. How would you reconcile that with your study? Thank you. Yeah, so that's a great point and obviously not addressed specifically by this study, but I think that the real take-home is that we don't have a lot of long-term outcomes after isolated biceps procedures, particularly when you consider radiographic follow-up beyond five years. And so arthritis is a decades-long process, and it's not that the biceps tendon protects you from arthritis, but in these cases, potentially sacrificing it or removing it from the glenoid could predispose to it. But I wouldn't say, and I also would say that in the arthritic patients, the biceps tendon is never normal. It's usually hypertrophied and histologically, it's tendinotic. And so is that just from chronic synovitis or is it playing some role in trying to resist that posterior wear that you see in osteoarthritic patients is to be determined. A couple of questions for Dr. Grusky. I'd like to start with a comment. Again, I applaud you on your work and these are good outcomes in a very tough patient population. Two questions. One is, I didn't see any measures of generalized ligamentous laxity, like a Bighton scale. And if you have any comments on whether any of these patients had generalized ligamentous laxity or diagnosed with Ehlers-Danlos, et cetera. The other question was regarding rotator interval closure, whether you have changed your practice based on your results with some potentially slightly better outcomes, or fewer failures than those that underwent interval closure. There's some selection bias there, certainly. Yeah, so the first question is a great one. We did not have the underlying Bighton score or information about generalized ligamentous laxity. And as I mentioned, that's probably the main criticism of the study, given the patient population that we're looking at. Certainly, I think one way we tried to look more into that is by stratifying patients by, based on their questionnaire, they let us know whether this kind of came on atraumatically or whether it was a traumatic dislocation. And certainly there are phenotypes of patients with generalized ligamentous laxity who have traumatic events, and there are patients who have atraumatic instability that are ligamentously lax as well. So that was the way that we tried to at least stratify between ligamentously lax and maybe more traumatic underlying non-ligamentously lax patients. But certainly having that information would be valuable. Secondarily, the rotator interval closure. I didn't include a slide, but we did look at the compared postoperative outcomes for patients who had the rotator interval closure and the patients who did not. I took the slide out like 30 minutes ago. I should have left it in. But basically the patients who needed a rotator interval closure, which was determined at the end of the procedure once the shift was performed, if they still had residual inferior anterior laxity, it was performed, those patients had worse preoperative outcome scores. And then when looking at their final nine-year postoperative outcome scores, they were even to those who didn't need a rotator interval closure. So what that tells me is there's certainly two different patient populations. There's certainly selection bias, but if you have to do the rotator interval closure, it did work well in that patient population. So following up on that, how did the results of this study impact the way you think about a treatment algorithm that may include things like an open shift? What patients would you most not prefer to perform this type of an operation in? You know, I mean, I think that certainly our results were very good across the board, even in the atraumatic dislocators. And you also asked about Ehlers-Danlos or syndromic laxity, and we did not include any patients with that. So, you know, you may be starting to think about more open procedures in patients who have issues of syndromic laxity. I think our outcomes were very good, and certainly with the arthroscopic approach, you're not violating the rotator cuff at all. And so, you know, you start to look at this study, you say, hey, if patients undergo a year or more of non-operative treatment and they're still unsatisfied, does it make sense to try this pain capsular shift? It's relatively low morbidity, has very good outcomes, and if that isn't successful, then maybe go to a more morbid approach. Dr. Dickens, with regard to your study, I mean, really well done, and I think a lot of useful information came from it. How do the findings in that study change the way that you think about this problem in your practice, the way that you will counsel people, indicate people, and are you gonna start doing acromial osteotomies? Yeah, the first, or I guess the last point first, that's certainly not the point of the study to start indicating, but I think what it is helpful for is posterior obviously is much different than anterior, and Dr. Bradley, Owens, everyone's kind of led into the notable differences in the two types of instability, and how we treat posterior instability is harder to kind of elucidate since it does present more often as a repetitive posterior subluxation and trying to indicate the right patients for surgery potentially early, and so I think this gives us some feedback on what are the risk factors that we can predict earlier, acromial height, bone loss, and subluxation that we can say, okay, these patients are more likely to fail, you're more likely to have increasing bone loss if you have these risk factors and fail, so perhaps these patients might be better treated early. Obviously, it's just a retrospective review. We don't have prospective comparative studies, but at least points us in that direction for these patients. I'd like to thank our authors and to ask our panel to come up. Thank you very much.

orthopedic surgery

shoulder injuries

slap repair

biceps tenodesis

instability population