We're going to hand it over to Chris and Pat. I'm going to invite Lee Kaplan, Jeff Guy, and Seth Gammarat up here to join this esteemed panel here. You guys have 20 minutes, you guys have... Okay, perfect. So this is the last part of the session, and I'm Pat Smith from Columbia, Missouri, and my good friend Chris Kading from The Ohio State University on the right. So we want this to be super interactive, so please get out your phones. We've got two ways to do it, either get the cue card off your phone here, the QR code, or you can go to the app where it says Session Q&A. But we have seven cases to go through, we're going to go through quick, we're going to have some panel questions, but we want the audience interaction here as well. So everybody, I'll give you a second there. Grab the cue card. All right, here we go. So here's our first case. Primary anterior shoulder dislocation, early season, no bone loss. So what are you guys going to do? Are you going to rehab, return the plane to brace, are you going to proceed now with arthroscopic stabilization, or are you going to stabilize them after the season? Okay, let's have our vote from the audience. Primary shoulder dislocation, no bone loss. What do you think? Okay, pretty clear, back to play. So let's start with our panel real quick. Jeff Guy, what are you doing in South Carolina? I mean, pretty much the same thing. It's surprisingly not always successful. I mean, they have to have full range of motion and full strength, and we usually brace them. And some of them tolerate braces. It's also very dependent on their position. So are they a linebacker, defensive people, I think, have the highest rate of re-dislocations. So we're a little bit more cautious with the defensive players and when we let them go back. But I think that that's pretty standard, the top one. Great. Okay, so let's go on here. So this is my next question for you. So he subluxes again, there's four games left in the season. Now he subluxes again. What are you guys going to do? Give him another MRI? Are you going to keep him playing when he's comfortable, or are you going to stabilize him now, or are you going to wait until after the season? So audience, what do you think? Got a vote here. So panel, Seth, what are you going to do here? Sublux again. Well, at this point, you got to have a real good discussion with the player and his family. I would repeat the MRI and make sure that it hasn't changed. There are certain MRI findings, like a big, bad, huge labrum tear, you want to go after right then and not stick him back out there because he's unlikely to be successful. But if the MRI is favorable and the athlete understands the risks and benefits, I would just plan the surgery for January, send him back out there one more time, with the thought being that if he subluxes for a third time, he's done. Okay, so we know that you have bone loss after a first injury dislocation, now you have a second subluxation. Do you worry about bone loss in a case like this, Lee? Does that make a difference to you now, knowing your data on that? Yeah, bone loss would make a big difference. I'm also concerned of a haggle or reverse haggle. You know, the soft tissue can really be affected. You could have a split of the capsule, you think of that in pitchers, it could definitely happen in defensive backs, linebackers. Position still matters to me. I mean, the only way that I think if you have some of those, you're playing this kid, is if it's a non-dominant arm and a long snapper, or a kicker, and we've had kickers have this and we've played it with them, let them play it out, and just told them not to tackle on kickoffs. We've pulled them off kickoff, actually. But I think that there's a problem with the soft tissue here. Okay, so Chris. So we've got a clavicle fracture in a hockey player. College player, good player, big contributor to his team, but has no chance of being a professional athlete, senior year, six weeks to go, has this fracture of his clavicle. Are you going to treat him non-operatively, say you can return to play after we see radiographic union? You going to plate him, let him return as tolerated, or plate him and not let him return until you have union? All right. Walt, what are you going to do with this guy, college? I'm going to let it heal and play him when he's ready. Lyle? It depends on, I mean, if the guy really has a chance to get back and he's important, I'd aim towards number three, plate, and return to play as tolerated, potentially. I think this is going to displace if he tries to play within 12 weeks, potentially, without surgical treatment. I actually think he'll return faster without a plate. Jim, what do you think? So this is a Division III team captain, really wants to play, six weeks to go in the season. Do you let him play with a plate? I'd probably not. I'd do what the audience says. I'd probably go non-op unless, for some reason, his parents really were pushing me, which I mean, I surely could plate him and get him back, but I'd think non-operatively, but I'd do nothing. The real question is if he's going to go to the NHL. That's the real question. He's got no pro potential. Okay. Then I'm letting him heal. I think the real question is, with non-operative treatment, what percent of that kind of fracture will displace during healing? Seth, comments? Yeah, we've had some problems with re-fracture, for sure, in our non-displaced clavicle fractures for USC football, and so I've gotten more aggressive with any clavicle fracture, unless it's a super convenient time. More aggressive plating it? More aggressive plating, because they heal slowly, they've got lousy vitamin D levels, and they do better with a plate. Walt, NFL player. Change your mind? No, not really. Not really. I mean, any displaced clavicle fracture, for sure, fixing with two plates, not one, allowing full range of motion right away, and return to play when they demonstrate radiographic healing on the CT, which can be fairly quick. All right. Okay. Okay, so here's our next case. So this is a radial tear mid-lateral meniscus on MRI. He's an elite defensive tackle, college football, big guy. What are you going to do? You're going to inject him, you're going to let him play now, keep him going, you're going to go to surgery, trim it out, you're going to repair it, fit him with a brace, let him play, or just get him through the season. What's the audience think? Radial tear, mid-body, elite defensive tackle. Okay, so everybody wants to fix it. Very good. Football, NFL guy, mid-season, what are you doing? Can you show me a picture of the tear? I can, in a minute. So if the tear doesn't go to the rim, he doesn't have mechanical symptoms, he's not swollen, then I'm going to watch him and let him play based on comfort and probably use a little PRP lubricant in the joint, you know, just for comfort from the original injury and let him return. So if he has mechanical symptoms, he's swelling, he's painful, then I'm going to go fix it. And the ones that require that typically go all the way to the rim, and the ones that don't go to the rim can be asymptomatic forever. And sometimes incidental findings if there's not a physical exam that goes along with it. Okay, well this one was symptomatic. So now, what's everybody going to do now? This is his scope. Are you going to trim it? Are you going to repair it all inside, inside out, repair it with PRP? What's your vote? JB, what are you doing with that tear? I'm fixing that tear with a rip stop, because lateral meniscal tears in professional athletes, big guys like that do terrible. The joint goes to crap really quick. And I'm using platelet-rich plasma at the time, and I'm going to make a little nick and a notch so it bleeds. Well, anything else to help us with? Well, I mean, I'm with Jim. And one thing for sure, almost anything on the lateral side heals if you do a good repair. That's not necessarily the same thing on the medial side for sure. And so, you know, the repair technique is always dictated by the tear pattern, and these can all be different. That's a radial tear with a flap, and it's going to be, with my standpoint, some all-inside sutures and some inside-out sutures probably both combined. Yes, I agree with that. Lou? Yeah, I disagree. I think that particular tear, you know, the inner, the part that's actually torn, I'm not talking about the peripheral rim. If it goes all the way through the body, you've got to fix it, there's no doubt. That particular tear, that peripheral rim of three millimeters, another two or three millimeters from that edge may heal. I think the inner two-thirds probably won't heal. And so, you know, unless I'm really at a point where, you know, this kid's going to take a lot of time off, I would just take that little piece, that part out, realizing he's going to have some risk of lateral compartment wear. I just, I think it's unrealistic to expect all that to heal. Well, I think that, you know, the partial lateral mastectomies in those players, particularly those big guys, I mean, it's pretty devastating, right? We've all seen that, so. Yeah, I agree. I just don't know if partial lateral repair works in those players. I guess we'd have to have a series of those to see how many didn't have symptoms five years later after repair. Well, we all know it's a common injury we see. It's a tough decision. Good discussion. Well, the good thing at Alabama is they're all gone before they take care of it. Exactly. That's right. You don't have to deal with them anymore. They get drafted, and you've got to take care of them. Yeah, they're gone. You've got them for four years, and they're gone. You give them to us with a bad compartment. Chris, you're up, bro. All right. All right. A systematic sprain, high ankle sprain, defensive back, football, six weeks left in the season, team's doing well. On stress testing, a minimal opening on fluoroscopic, but he can't toe walk, and it's just the injury just occurred yesterday. Can't toe walk, appears to be stable. Are you going to stabilize him or turn him on off? Yeah. We have this exact question in the TPC course. Professional quarterback, Super Bowl's in two weeks, needs to play, two tightropes across there with a little plate. You've got to use the plate. If you don't use the plate, they can fracture their fibula, but I'd talk to his parents and do them as soon as I could. Before, Lyle got this, right? The two-a-tightrope, yeah. Lyle started this, I think, at Alabama, and that's absolutely right. These things linger forever, and if you fix them acutely, you can have them back very, very quickly. I think that's the right. We had this exact case at the team position controversy course. I had four of the best foot and ankle guys in the country, and they all said the same thing. Fix it. Lee, you agree? You got any other comment? No. You have one guy that's pontificating, that has the experience, and then Lyle has pushed the limit. What I would ask Lyle, though, is about protecting those guys, because at least your quarterback that you played was pretty well-protected, it looked like, you know, in his ankle. How was he moving? And then, Jim, how was your guy moving? Yeah. Just to kind of clear the air, my foot and ankle guy, Norman Waldrop's kind of the guy that came up with this philosophy from Tom Clanton and Bob Anderson and others. We did it on two tango below, obviously. I think what you do with the tightrope that Jim described, the two tightropes and the plate, is you convert an unstable injury into a stable high ankle sprain. And so, at that point, you would do what you typically do in a stable high ankle sprain. So, you still tape them, you still protect them, you still treat them in a boot when they're not playing, you still treat them like a stable type once in an osmosis sprain, but because it's stable, they come back to play quicker, which is an advantage. So, Lyle, the player, the parents, the coach, they ask you, how long? How long before I'm back on the field? Depends on when the game is. Jim, you got a comment on how long? Oh, for this, we've had that. You can get them back within two weeks, three weeks. I mean, what he said is true. It's a stable high ankle sprain. Now, you've got to do, we have some special tape jobbing things, and we don't beat them up at practice a lot, but that's exactly what happens. The first guy that had this actually wasn't too, it was a guy named Cam Robinson, and he played in six days as a left tackle with two tight ropes, tape, you know, he basically had a cast on his leg, but it was a different position. So, I think it depends on position, the game, the player, their mental status, all those things. So, the opposite question real quick is, how many of these have you seen that you treated conservatively that stayed symptomatic for most of the season, and you end up having to go fix it in an off season? I'd say too many to count from my experience. Yeah, the tweeners are the one you're in a problem with. It's not the stable ones or the really grossly unstable ones. It's that gray zone in the middle that they just linger and linger, and they can't get up on their toes, and then they slowly can get up, and then they re-injure it. They'll tweak it four to five times the rest of the season. Yeah. Okay, let's move on. We've got to get to it. You know, the shoulder case. So, this is a quarterback, dominant arm, AC joint, grade three injury, so what's your treatment? Are you going to inject him, let him go, observe him, just think about operating on them now or surgery at the end of the season. So, audience. So, JG, maybe dominant arm, quarterback. We've got a bunch of professional guys like this. We basically get them asymptomatic. I have two starting quarterbacks, three starting quarterbacks in my career so far that had grade threes, didn't operate on them, they all got back. And the one guy played for 15 years. So, unless they force me, I'm gonna inject them with platelet-rich plasma, which we've shown works really well because of its anti-inflammatory effects and I'd let him play as soon as he's comfortable, as soon as he can throw. Lee, any thoughts on it? Yeah, Bradley and I've had this conversation a lot. We seem to have quarterbacks that keep landing on their shoulder. One of them came over from Houston. I would say there are two things here that are important to me. First of all, I agree with the audience. I have had grade one turn into a grade three in the following game, which I'm fortunate, just driven into the turf. He couldn't even pick up his arm after two weeks. We just fixed him. Recently, Lyle tried to steal our quarterback and we dealt with something like this and we did exactly what Jim mentioned. He came back, he did land on it again later in the season and they just, for other reasons, said you're done. But, I think you inject them. I do believe in PRP and we really get after them in the training room. We let it go down a little bit, but I think, you know, initially that they get really concerned. And then, I'll just answer this question. I mean... So, let's for the audience first. So, let's say you guys, he says, I need to be fixed. End of the season, you waited. What are you going to do? Are you going to do an anatomic two-tunnel technique? Are you going to do arthroscopic graft only? Or, I'm sorry, button with fixation with a graft or only with the button? Or, you can do it open? These are your choices. For the audience, what do you think? How are you going to fix this AC joint that you end up operating on? So, Lee, what's your go-to here? So, my go-to is the button technique with the graft, which seems like it's winning. I did do the two-tunnel technique, the anatomic technique. I really liked it. I did in line and I did it with guys that hit. But, I started hearing some rumors about the fracture issue. And, we've been really happy with just the button and the graft. And, we have a bunch of kite surfers in Miami who seem to land funny. And so, this is becoming, you know, something we see commonly in clinic. And, the other thing is, when you do it just with the tunnels or just with a graft, you can still see that it leaks, you know, approximately that there is some movement later on. The buttons really keep everything well aligned for a long period. Yeah. But, they all tend to come up some no matter seemingly what we do. It's a tough one to get anatomic and keep it anatomic. So, like Dr. Andrews always says, don't get another x-ray after you fix them. Everything will be okay. So, all right, let's go. We got to get a couple more cases in. We're running short on our time. So, this is a slap tear at a collegiate baseball player, been treated conservatively. Rehab, just couldn't go after extensive treatment. What are you going to do? Are you going to inject him? Are you going to operate on him? Do a biceps stenodesis? Or, are you going to fix that superior labrum? What's the audience going to do for this symptomatic slap tear? This will be interesting. Okay. Seth, what do you got? Yes, he got here. Okay, if the biceps is perfect and it's a young athlete, you know, in their late teens, early 20s, I'm still doing an arthroscopic superior labrum repair, keeping the anchors behind the biceps, nothing in the front, so they don't get too tight. But if it extends into the, if the tear extends into the biceps, or if there's a predominant symptom of bicipital groove pain that they have, then I've had decent luck with biceps stenodesis for this injury. But I think that it truly is about a 75% success rate, either operation you choose. I don't think the stenodesis is going to be a home run either. Well, I just said stenodesis because Dr. Bradley's going to jump out of his chair. So, biceps stenodesis is in your hands, JV. Look, so in my study group, there's 1,700 posteriors, and there's 228 pitchers, and there's 488 throwers. All of them had a slap repair for that. It'd be symptomatic. Our failure rate was 6%. So, why am I taking something that the good Lord put where it belongs and moving it somewhere where it doesn't belong after a millennium of, you know, Darwinian theory? Jeff, Jeff, you got an answer for the professor there? Yeah, I mean, I do, I do both, but it's also a conversation with the patients. I think that one of the things for the patients is that the difference in time for a return to play. All right, well, let me, let me just go on for a second. This is his rotator cuff. This is well over a 50% tear. So, is it in the cable or is it in the crescent? It's in the cable. Yes, it goes. So, for the audience, you're going to debride it, posture repair, or take it down. So, let's tell me, audience, what are you going to do with that deep partial tear? It does involve the anterior cable. A lot of debridement, not much fixing. Wow. But, but I would argue for both the slap and the rotator cuff, your best return to play by far is not having surgery. Even though Jim, I know Jim says it's 94% success rate, but if you look across the board, isolated slap without rotator cuff, anywhere from 40 to 70% return to play. You add cuff, it probably goes down significantly. So, you know, the goal would be not to operate on this kid. Once you operate on him, debridement, certainly better. Well, if he can't, if he can't pitch, he's going to just end his career and just leave him alone. Well, wait, wait, wait, wait. A symptomatic slap has three things start. The guy cannot warm up. He loses control. His ball starts going. He loses his launch window. It goes high and outside. It's very typical. And his velocity drops eight miles an hour. You got to do something. And to me, if the cable's involved, you got to fix the cable too. Your chances of them getting them back aren't as good when you do that. But if it's aggressive, you just debride it. So are you doing a posture or you're doing a takedown? You can take down and fix it. I'm taking that down. It's in the cable, right? I'm taking it down. I'm doing a kind of a mini double row repair arthroscopically. Seth, nodding your head, what do you think? I would debride that. I don't think that the rotator cuff repairs in overhead athletes do great. So unless it's nearly all the way through, I would clean it up only. Okay. All right, Chris, you got another one? All right, Jones fracture, basketball player, Division III, college, senior, six weeks to go. He's got lateral midfoot pain. He got the x-ray. He's got the Jones fracture. He says, I want to play. This is the end of my career in a month. My organized sporting career is over. You're going to let him play as tolerated until the season, then fix him afterwards? You're going to operate him now, let him play as tolerated through the season? Or do you fix it now and say no playing until you get radiographic healing? Audience? Lee, what do you do with this guy? Well, first of all, I wanted in the minutes that Bradley used philosophy, religion, and science in one answer. That's pretty good. You know, this is a very tough one. I think, you know, we are at the discretion of the athlete. I think the audience is doing what everybody will do post-NIL. But, you know, if he wants to play, I mean, I couldn't fully see it. I'd need to see it again or a CT. But if it's unicortical, you know, starting to go across, I mean, the smart thing to do is to fix it. But I'd probably talk to him, tell him what was going on, and allow him to play and then put a screw in. Anyone different? Walt? Well, kind of the same thing as Lee. It sort of depends. I mean, if they're truly symptomatic, they're not going to be able to play. If they're completely asymptomatic, then I think you can watch them and let them play. So you'd fix them and let them return to play as tolerated, even if without evidence of healing? No, if they're completely asymptomatic, because we've seen a bunch at the combine that come in that are picked up on ankle x-rays done for different things that have probably been there for an entire season or most of the season. And so those, I'll be very slow to go with. At the end of the season, that's a different story if they're there. So you, if the pain's tolerable, you'd let them play on it and fix them after the season? Yeah. Jeff? Yeah, yeah. Yeah, we had one of these this year, and we were about four weeks before the season for women's basketball. And, you know, a lot of it has to do with the type of player and what they're thinking, but we fixed it. And she came back in about three or four weeks, and she did great. So you let her return to play as tolerated? I mean, we held her back that first week to ten days in rehab, but not a lot of impact. But then, as the pain went away, we let her progress. With the discussion that, you know, if this doesn't heal at the end of the season, you may need to be bone grafted. And so she did great. So Lyle, you decide to fix it. You're gonna put a screw in it? Are you gonna put one of those plates? Yeah, so it kind of depends on which side it's on. If it's an inferior stress area, we'll usually put a plate on it. The typical Jones, it goes all the way through, we'll put an intramedullary screw. But again, you know, if they come back early, most of them can play with it. They can come back early and play with it after you fix it, but a lot of them go to non-union. So you have to be prepared to go back and bone graft it when the season's over. Chef, plate or screw? We use a screw. These are problematic injuries. We had a recent baseball player who we let play through the end of the season, and he did fine, and we did a screw after the season. So this exact scenario, you guys did a great job selecting these cases. So Lee, you're gonna put a screw in it? You're gonna do some kind of biologic augmentation at the time of the index surgery? Yeah, I mean, we are pretty aggressive in doing some PRP, but also bone grafting, and then trying to do some stimulation as well. I just have one question for Seth. Did you guys, in this situation where we allowed somebody to play, we did some special shoe inserts. Did you guys change the kids cleats, especially with spikes? Yeah, he had custom orthotics and then a carbon fiber plate, and he did pretty well. But baseball, obviously, they're not running very often. They run a little bit. So I think it'd be different. Walt, are you gonna put any biomagic in that bone? Well, I think we're gonna fix it, yes. I've even done two NFL players that just had injection of BMA after a season with the minimally symptomatic and bone stem that both went on to heal completely, and I'd like Bradley's opinion, because the worst results you see at the combine are the ones with the big Bob Anderson screw. The lack of complete healing and failure is pretty common with that. The ones that look the best are the ones that look like the worst surgery is done. The tiny screws not down the middle of the fifth metatarsal into the cortex, some things you'd think that was a terrible surgery, and they look bad on x-ray and heal completely, and the big thick screw designed for this, I think, has a really high non-union rate, which is why Varner, our foot and ankle guy, started doing plating and plates. Most of them in the union rate we've seen be much higher. So, Jim, we had an argument with him. I mean, Bob sends them back really early, so when he's presenting his cases, I sit back in the back, and I go, Bob, you're sending them back at like three, four weeks. I mean, you know, I'm waiting until I have some, you know, eight weeks at least to make sure, and I CTC them. I don't like to CT them early because of the radiation, but when I think they're 80% healed, I CT them. We send them back. So it could be when he goes, they go back. Plate or screw, what are you guys using? Well, I've done both. I've used plates, and if they've been chronic, I use screws. I mean, excuse me, I use screws most of the time. I use plates. Like Lyle said, I use plates there. I always use biologics. We take some bone marrow out of the calcaneus. We slurry it up with platelet-rich plasma, and we always shoot it at the fracture site. Lyle, anything else to add? No, I mean, I think you just have to realize that, again, these players can play with this. This guy might be able to play with it without surgery. If he can't, he can play with it quickly after surgery, but the non-union rate is significant, which is what Bob's saying with his cases. All right, thanks a lot, Pat. I think we're over. Yeah, that's seven cases, crossfire. Thanks to the panel. Thanks, panel.

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