if you have any questions and we'll start over here with Keith Kenter. How are you? There we go. So Steve I couldn't figure out how to ask questions on the app but I did see the heading that need help. It didn't help me. So Dr. Kahn, Keith Kenter from Kalamazoo. I really appreciate that the distal radius and the curvature radius. So congratulations on the thought process and I've always wondered and I wanted your thoughts does the thickness of the cartilage mean anything and did you compare thickness of cartilage with the distal radius and the distal tibia or is it doesn't matter because that can contribute to the curvature radius. Yeah so we didn't directly compare it we did look at you know our CT analysis obviously doesn't include cartilage versus right when we're doing the cadaveric it does. So I don't we didn't actually look at the actual thickness and how that would contribute to it. I don't think the thickness would necessarily change your stability but that may you know contribute to you know long-term arthritis progression would be my thought. Thanks. Dr. Kelly. It's father Kelly thank you. Come on Albert get it right. My bad. One wonderful panel I have a question I would like to ask Dr. Lin who's clearly a lot smarter than I am and the panel weigh in. Why does REMP massage eliminate apprehension in an on-track lesion? I haven't wrestled that question but there's some recent data suggesting that. Well you know I think I think the track concept is I think a deficiency of it is is that it's just bone morphology right and so you're you're you're actually not really looking at a huge soft tissue component which is which is which is important. And we know you know let's say a hyperlaxed patient even though they're going to have an on-track lesion we know they're going to recurrently dislocate even if they're nowhere near off-track. So there's some soft tissue component that even if you have an on-track lesion I think is going to matter regarding sort of how likely you are to engage or not engage. And I think if we're gonna use those terms the I think the other thing is you know when we do these measurements right and we have a on-track lesion that is one millimeter from being off-track two millimeters from off-track do we really trust that that is a really an on-track lesion and we I don't know that but I I have a suspicion that there's a big spectrum that you can be a little bit on-track or a lot on-track and that might matter regarding your dynamic stability. And scapular protraction affects the track measurements so perhaps it's just that pulls the head back is that what you're saying? Absolutely yeah. Wonderful session thank you. Thank you John. We have some questions from the audience and so this is this question is from for Dr. McCarthy. So the question is in regards to chromium morphology in patients with a non-supportive arch to posterior instability what augmentation techniques would you consider or suggest and would you consider rotator interval closure? I think it's a reasonable thought. Dr. Gerber actually previously mentioned did just publish a case report on doing a full-on acromial and glonoid osteotomies for a patient with a fixed posterior static subluxation of the humeral head with success there. Certainly opening wedge posterior osteotomies have not had a phenomenal track record in the the case reports that have been a series that have been published but you know perhaps for certain patients who have more severe bony anatomy that could be something that could be considered. Dr. McCarthy I was going to ask you as well how are you applying this in your practice? I'm assuming now when you have a posterior instability patient are you measuring this and I know in your talk you said do a robust repair maybe go slow with rehab but I'm sure you do that every time. So how are you applying this and do you think you'd ever consider the osteotomies of Dr. Gerber? That's pretty pretty impressive. Yeah it was cool looking x-rays. As a resident I'm deferring to the staff's choices obviously but I've already had some staff. But you're going to be a doctor on your own. Hopefully. We've been looking more closely at the sagittal MRIs and taking a look and seeing what the acromion looks like and you know considering that hey this person may be at high risk for failure maybe we should tell them that and like I said maybe we should consider using more anchors maybe consider again slowing rehab. I think it's a counseling thing and it's potentially an intra-op decision-making thing. You know maybe we're not ready to start an osteotomy as everyone yet but you know I've got some time to finish residency and see where that goes. Dr. Dickens. I think it's a very worthwhile question and in sort of multiple faceted. I think a lot depends on bone loss. The cromial morphology certainly predicts how these patients will go as we're talking about non-operative versus operative to begin with and so I think it's helpful for counseling. But one of the things that's interesting is the posterior stabilizations rehab slower and have a longer time to get back their strength and performance compared to the anterior cohorts. And we don't you know to yet we haven't looked at the impact of this for that so I think that this may play a role potentially in some of that residual rehabilitation. And then you know in terms of treatment solutions it might be a predictor but really I think the the treatment algorithm may come down to what is going to be presented in the next session which is kind of bone augment solutions that might be more akin to the anterior solutions as well. So I think there's certainly a lot to be learned and I think that the impact of this at least in my mind is just the recognition of the factors that play into posterior instability because this certainly seems to be an important factor at least in identifying posterior instability. And then while you're standing there I can ask you and Dr. McCarthy what do you think the role of an external rotation brace is if you are really worried about a patient? Do you do that? Do you think it makes a difference? Yeah I think that's a great question. You know personally I think you have to weigh that against the patient population. It's not routinely kind of tolerated for long periods of time at least you know beyond six weeks or something like that. So I personally I don't know that we have the literature that says strongly one way or the other what that is beneficial. And then do we have time because we're a little bit off so so very rarely do I get a chance to pick on a mentee here in front of a live audience but I'm going to pick on you Ting. So you've done great work to doing this this study. So tell me how your study you know you're going to be in practice and you know you're going to be out of fellowship in two weeks. What is the inferior caudal or sort of caudal extension going to play a role in sort of how you think about instability going forward? Yeah absolutely Dr. Lin you taught me about the mid abduction apprehension or even the adduction apprehension for patients who are at relatively higher risk and have a lower threshold to do something more than just an arthroscopic Bankart. We don't really know yet this is you know first study looking at this whether it should change clinical practice and I think what we want to do or should do is to correlate our finding of a mid abduction apprehension to this before we should say hey there is a clinical correlate I think it should make a difference as to what surgery I do. So I think it does warrant a little more research before we start jump into any conclusions. A political answer I love it. And then we have one oh Dr. Arcero. It is yes and it's for you. I love your work. What I want to ask you is what role does the exam under anesthesia have in your algorithm and does it correlate to the near track off track concept that you have in your practice? That's it's really good question. I try not to base my decision making on what I am going to see intraoperatively. I try to make all those decisions preoperatively. Now we do an exam under anesthesia and there's somebody who has let's say you're planning an arthroscopic approach and this probably rarely happens but you do an exam under anesthesia and they're extremely hyperlaxed. You can push the entire it doesn't matter how far on track this is and you just can push the entire thing out. Then I think it might change my decision about sort of how much augmentation or what other approaches I will do to try to limit that. But I think for me I rarely I try to make all the preoperative decisions beforehand so I'm not trying to guess intraoperatively after the EUA. And then Albert I have a question for you. So I'll pick on you since you picked on Ting. So how are you using I'm assuming you're calculating your distance of dislocation. How many times are you changing your plan? Are you adding remplisage into your laterges often or do you find yourself switching to distal tibia? Yeah so I think it's interesting because I think I think the latergy is a very effective procedure but I think there are some there are some scenarios I think where we kind of might worry and let's say like a like a high-risk seizure disorder patient which that was not in the cohort but let's say a high-risk seizure disorder or they have such substantial hillsex defect that even if you put a coracoid in the front that you're still sort of not really you haven't really restored their track. That is a type of person on occasion that I would say okay let's change this approach or maybe I should do a remplisage and do a latergy or take a bigger bone block maybe that's needed but I think it happens rarely but I think as a concept it does enter my decision making particularly with a high-risk patient. And then Dr. Khan we haven't picked on you enough. So have your have your mentors done this yet? Have they used distal radius? Do they have plans to? Not for instability. Dr. Jerry Williams actually did a case where he used it for posterior instability in the case of doing a hemi and saw good success with it but not for anterior instability yet clinically. And do you know how readily available the graft is compared to distal tibia? At the hospital that we did this at it was pretty much equivalent to the distal tibia and cost was pretty similar as well. Dr. Khan I do really like the the study and sort of how well it restores. Their question from the audience is do you have any concerns regarding graft osteolysis with this graft choice and or technique? Any different than than the other available graft choices? I wouldn't imagine there would be any difference than you know distal tibia or other graft options that are available in terms of allografts. All right I think that will wrap up the paper session. Any other audience questions that we didn't get to? No I think we got to these. Can I ask you a quick question on your study? Oh boy okay. I know we're coming at you. Just a technical portion. So latergé when you do it what's your do you think there's significance to the sling effect? The way you do a latergé does that is that something that kind of augments the stability? Do you think there's a role there because if you move to a larger graft for example like a distal tibia sometimes the actual technical nuances are different so I'm just curious. You know I think there is a sling effect although you know I think I think some studies are going to debate that a little bit and I and it's interesting you know Matt Preventer and Rachel Frank have have have you know kind of compared latergé with DTA and there's doesn't seem to be much of a difference and one of them clearly does not have a sling sling effect source. Personally though if you if you just you do it and you look at it there's for me I mean that's one of the reconstructive you know benefits of a latergé but I think you're going to get some varying opinions in biomechanical studies and clinical studies looking at how much does that sling effect actually actually work. Right. Yep. All right great. So let me see my phone for one quick second. So the audience question so a lot of you were able to figure it out but to help out Keith and maybe the one or two other people who are having difficulty so if you sign into the session so go to the actual session and you'll have the option if you scroll down it'll say Q&A click on there and then you'll be able to ask a question just click ask and you can type it in and it'll go right to the moderator. So if you want to come up to the microphone absolutely do that but another opportunity to make sure you ask questions. So I want to thank the the presenters here and we'll move on to the next portion of this session.

orthopedic surgery

cartilage thickness

stability

arthritis progression

soft tissue components