if we have a second. Beautiful. It's really a beautiful video there. We've been informed by John and Jim Bradley and those with critical posterior bone loss. That seems to be a nebulous target probably just as much as anterior is now, I guess. But what's your threshold for doing this? How much bone loss do we need to consider this? That threshold is going down significantly every year, it seems. And I think that critical 13.5% or around there. It's more of a consult too. When you see that CT scan, you see that malunited fragment. In any hint of bone loss, I think you're going to be at high risk for instability if you don't address that. Some people will talk about trying to elevate that malunited fragment up, but that bone is kind of resorbed already. It's obviously not its normal dimensions that it had before. It pulled off and resorbed. So I think I have a very low threshold for doing this. Question for you, Grant. So I don't know how far out you guys have followed. It sounds like you have a series at least of these. Do you follow these out? Do you see any bone resorption or remodeling? What does this graph do in the back? You start with like a rectangular graph that actually extends beyond where the native glenoid typically is. Does it? Yeah. So really only one that we followed out long is that gentleman that I presented at the end. So he was four years out and he was doing well and he actually sustained a rotator cuff tear. So this was great. It was allowed us to get that imaging again. And really, I mean, the bone block was substantial. The screws hadn't loosened there. And we went in there and that graft had incorporated nicely, probably had a little fiber cartilage interface between the graft and the native glenoid. So very, you know, very encouraging to see to see that, that that does heal. And maybe not all of them do that. But in his case, actually, we got a pretty substantial healing. And the people that we've done it on, you know, they we haven't had any issues. Obviously, we should probably be bringing them back long term to see. But so far, you know, we haven't seen a whole lot of resorption of that. Great. Thank you, Matt. Grant, thank you and everyone. Outstanding work, really, I think taking this to the next level and all the bone graft techniques. And we've, you know, Steve's point also, we've actually we have early outcomes in terms of graft resorption anterior versus posterior. We have found a little bit more posterior. I don't know why that is. I think it's but in general, even like Ivan has shown us, we are getting remodeling almost like the glenoid. And keep in mind the latter, if you look at Giovanni DiGiacomo's work, 57% of the coracoid quote unquote resorbs, but still with good outcomes. So I think we still have a lot to do in terms of the modeling and where we're at. And then the last comment I'll just make and or question for you is the difference in anterior versus posterior bone loss and the configuration of the bone graft. We've found some brilliant techniques, especially 3D printing and the angle posteriorly is much different than it's more like a cliff anteriorly. So appreciate your comments on that and how you're fashioning the grafts and some of the pearls for the audience. So thank you and great work. Well, thank you. I appreciate it. Yeah. So we, you know, we just, we basically just did the allograft and you know, the times that we've done it, you know, you get a nice, seems nice and flush and it seems to recreate the normal concavity. But yeah, it's right. Maybe we should look at that more, more specifically and kind of customize our grafts to everybody's anatomy is going to be a little bit different. So those are great points. We haven't done that yet, but I think that's something that we need to look to in the future. And then real quick from the audience. What do you, all of you do for reverse heel sacks because we shouldn't ignore posterior glenoid bone loss and John Kelly probably thinks we shouldn't ignore the posterior, you know, the reverse heel sacks. So do you do a reverse remplissage any of you? I do not, but it's definitely something to consider. Yeah, it's, I mean, it's, it's certainly a good option. I think it just depends on, you know, the size and the scenario is their posterior bone loss, the size of the heel sacks. So I think it's variable for me. It's not like we have a glenoid track concept for, for posterior that's worked out yet, but I think it'd certainly be nice to help guide something for treatment. I think it would depend on the scenario if it's a really high risk, a reverse remplissage is essentially interposing the subscap in. And I think the subscap in general, I think interposing it is a lot different animal than sort of just imposing capsule. So I think in a seizure disorder person, I would have no issues kind of doing that. But I think if it becomes a substantial defect, you're considering doing something on the, on the humeral head side, I probably would, would, would think about bone, like a bone graft source of some like talus or something else. And I think you also worry about, like you said, over constraining the joint, you pull that subscap over and that can really tighten them up in external rotation, which is less of a concern. There's more kind of play in that posterior rotator cuff that you're able to do that with a standard remplissage. Absolutely. All right. Well, I think we are done. Thanks everybody for a terrific session and Robin. That was a great session.

bone loss

shoulder joint

posterior region

treatment threshold

bone graft techniques