All right, so I'm going to get the session going. Welcome, everyone. We're here for Shoulder Potpourri. Hopefully this is fun and engaging. We've got an excellent panel who's from all over the country is going to be here with us. But we're going to start with some academic presentations. So our first one, Scott Feely is going to talk about overreduction of type 5 AC joint dislocations during acute fixation. Good afternoon. I'm Scott Feely from Walter Reed. And I'd like to thank my co-authors for the opportunity to present our work. Please refer to the app for our disclosures. Loss of reduction is a common complication following fixation for AC joint dislocations. Radiographic risk factors for loss of reduction and their association with failure to return to duty have been reported for a military population. But these were limited to small case series. Additionally, those studies define radiographic loss of reduction as an increase in CC distance of greater than 6 millimeters postoperatively. However, overreduction of the clavicle during fixation may affect the rate of radiographic loss of reduction and its clinical significance. Therefore, the purpose of our study was twofold, to evaluate loss of reduction after acute fixation of type 5 AC joint dislocations and to determine risk factors and outcomes associated with loss of reduction. To do so, we queried for patients with a CPT code for CC repair or reconstruction from 2013 to 2020 and reviewed the health records and imaging for each patient for the listed measurements. These measurements have all been analyzed previously as risk factors for loss of reduction specifically. We included only Rockwood type 5 AC joint dislocations that were surgically stabilized within six weeks and excluded patients based on these criteria listed. The primary outcome was loss of reduction, which we measured via two means. We defined radiographic loss of reduction in the traditional method as an increase in CC distance greater than 6 millimeters. We defined clinical loss of reduction as a Rockwood type 3 or greater on final imaging. Secondary outcomes included reoperation and return to duty. Here are two sequential postoperative radiographs which help to distinguish the difference between our definitions of loss of reduction. The yellow lines parallel the inferior and superior borders of the clavicle and help to show AC joint congruence. On the left, the AC joint is overreduced by 6 millimeters at a time of suspensory fixation as measured by the red line. We classified this subset of patients as a Rockwood type 0. On the right is the same patient four months later, demonstrating a Rockwood type 1 and thus no clinical loss of reduction, but with a greater than 6 millimeter increase that would be classified as a radiographic loss of reduction. Following the application of exclusion criteria, we analyzed 183 patients. Our cohort was predominantly active duty males with median follow-up of five years. By fixation type, there was a significant difference in time to surgery, and we categorized fixation types by these three groups listed. Half the cases were isolated suspensory fixation, and 18% had concomitant distal clavicle excision. Importantly, type of fixation was not associated with radiographic loss of reduction. The rate of radiographic loss of reduction was 37%, and the clinical loss of reduction rate was lower at 25%. Thirty percent of clavicles in our cohort were overreduced by a mean of 5 millimeters. Overreduction was found to be a protective factor, and seven times less likely to lose reduction to a Rockwood type 3, but was not associated with a decrease in loss of reduction when looking at the traditional method of radiographic loss of reduction. We were unable to identify, however, a threshold value for overreduction that was associated with loss of reduction. Five percent of patients failed to return to duty, and eight percent had a reoperation. However, neither definition of loss of reduction was statistically associated with failure to return to duty or reoperation. Loss of reduction was common in our study and consistent with other military studies, although higher than the rate reported in systematic reviews, and may reflect the occupational demands of military service members in general. Prior military studies have evaluated radiographic risk factors for loss of reduction, and have recommended specific conoid and trapezoid tunnel ratios to help reduce loss of reduction. In contrast, our larger cohort demonstrated no statistically significant association with these tunnel ratios or with many of the other radiographic measurements. The return to duty rate was higher in our study, but is consistent with other civilian return to play rates. Our study highlights several research gaps for future exploration. First, there's a dearth of literature when looking at overreduction specifically during AC joint stabilization procedures. Second, the difference in loss of reduction rate between various definitions and the protective nature of overreduction found in our cohort suggests that the traditional definition of radiographic loss of reduction may be inappropriate to evaluate clinical outcomes. Finally, a clear relation between return to duty and fixation method or maintenance of reduction remains elusive. In conclusion, clavicles that were overreduced in our cohort were seven times less likely to lose reduction, and surgeons should consider overreduction at the time of fixation to decrease the rate of clinically important loss of reduction. Thank you. Thank you. Great talk. Our next one is from Patrick Morrissey looking at two-point fixation for remplissage. Yeah, this one's for him. Hi, I'm Patrick Morris. I'm a resident at Brown. I'd like to thank my co-authors for their hard work on this study as well. I'm going to be presenting a cadaveric biomechanical study of remplissage technique. You can view our disclosures with this QR code, nothing related to this talk. So as we all know, anterior shoulder instability is a common problem in young athletic populations, and remplissage is an increasingly utilized adjunctive technique in shoulder instability surgery that has been shown clinically to decrease recurrence rates without significantly affecting functional outcomes. The indications for remplissage are expanding, but the optimal remplissage technique is not yet known. So there are several prior biomechanical studies of remplissage technique, some of which are shown here, but they've primarily focused on shoulder range of motion, and they've established that remplissage can lead to decreased range of motion, especially external range of motion, and with medially placed anchors or medially passed sutures. There has been less emphasis, however, on how anchor location and number affect stability for varying hill-sax lesion sizes. So the purpose of our study was to determine the ideal number and location of fixation points for remplissage of both a small and a large hill-sax lesion. We hypothesized that two fixation points, as well as medial fixation, would be more stable in both small and large lesions when compared to single fixation and central fixation. As for our methods, we made hill-sax lesions of 15 and 30 percent of the humeral head in sequential fashion using previously described technique by Sakaya, which involves placing the shoulder in the position of anterior apprehension to determine the orientation and size of the lesion. No Bankart lesion was made or repaired in order to decrease heterogeneity of our results. Transosseous suture holes were made for remplissage of either one or two points, and the location of these holes can be seen on the lower right-hand side of the screen, represented by the blue dots. Eleven conditions were tested, starting with intact, and then a combination of one central, two central, one medial, and two medial fixation points in each size lesion. Specimens were placed in the position of anterior apprehension, and testing was performed on a KUKA robot, as shown in the top right picture. The primary outcome variable was peak resistance to anterior translation. So, looking at the model, comparing the intact specimen to the small and the large hill-sax lesion, there was a significant stepwise decrease in stability, going from 45 to 37 to 29 newtons of resistance. Looking at the small hill-sax condition, all fixation configurations were able to restore intact stability. One central and one medial fixation point were statistically equivalent. Two central and two medial points were equal to each other, but both more stable than either one central or one medial point. Looking at the large hill-sax condition, all fixation configurations were able to at least restore intact stability. Again, one central and one medial fixation point were statistically equivalent, and two central and two medial points were again equal to each other, but both more stable than one point, either centrally or medially. Importantly, both two-point configurations, centrally and medially, were more stable than the intact condition. So, just a few take-home points. All techniques that we used were able to successfully restore intact stability. Two fixation points were more stable than a single point for both medial and central fixation, with no statistical difference between medial and central fixation. As for some clinical takeaways, we found that one anchor point restores native stability, regardless of anchor location or lesion size, which led us to conclude that two anchors may be unnecessary, especially given concerns about postoperative stiffness. Thank you. I guarantee my residents are laughing that they're letting me run the computer up here because they know. I'm not tech savvy. It's with great excitement that I get to introduce the next young man, Dr. Fabian Su from UCSF, who is currently one of our superstar residents and we're very proud of him. So, Fabian. Thank you, Dr. Edwards. Good afternoon, everyone. I'm Fabian. I'm a resident at UCSF. I'd like to thank the Education Committee for the opportunity to present our findings on whether MR arthrography improves evaluation of patients with posterior shoulder instability. All of our disclosures can be found on the AOSSM website. Posterior shoulder instability is uncommon, accounting for approximately 10% of all shoulder instability events. However, these injuries can be devastating as only 35% of young athletes return to sport at their pre-injury level at long-term follow-up. The diagnosis of posterior shoulder instability is often difficult given the lack of true instability symptoms and that the physical exam maneuvers have limited diagnostic test accuracy. Advanced imaging such as MRI can aid in its diagnostic evaluation and multiple historic studies from the 1990s and 2000s have previously shown an MRA to be superior to MRI in the diagnosis of labral lesions. However, these studies were limited by combining patients with various shoulder pathology and did not specifically evaluate patients with posterior shoulder instability. Thus, in the literature, the benefit of MR arthrography over conventional MRI is unclear. Furthermore, arthrography has several drawbacks and requires additional cost, time, and is an invasive procedure for the patient. Therefore, the purpose of our study was to compare the accuracy of MRA and MRI in detecting labral, osseous, and chondral lesions in patients with posterior shoulder instability. We hypothesized that MRA would be superior to MRI. A total of 310 patients with posterior shoulder instability were enrolled in this multi-center study. Patients with an acute effusion or previous labral repair were excluded. Thus, our final cohort consisted of 89 patients with conventional MRIs and 203 patients with MR arthrograms. A fellowship-trained MSK radiologist with over 10 years of clinical experience evaluated all images. He was blinded to all clinical information except that the patients had posterior shoulder instability. All MRIs were at least 1.5 Tesla and were obtained within six months of surgery. There was a slightly higher proportion of 3T MRIs in the non-arthrogram group. Sensitivities and specificities of MRI and MRA were compared using arthroscopy as the gold standard and standard statistical analysis were used. There was no difference between patients who received MRI and MRA except that the patients with MRA were younger. And on imaging, a labral tear was identified in 95% of patients. Most of the tears extended from the 7 o'clock to 11 o'clock region and had a mean tear size of 155 degrees. Imaging tended to overestimate this actual size of the labral tear by approximately 45 degrees. Compared to the gold standard of arthroscopy, both MRI and MRA had sensitivities greater than 95%, though the specificity was low. There was no difference between imaging types and the evaluation of labral tears. For glenoid bone loss, 12% of patients had evidence of bone loss at MRI compared to 4.4% on arthroscopy. The mean bone loss was 8%. MRA had higher sensitivity than MRI in detecting glenoid bone loss, though this was not statistically different. There was no difference in specificity between modalities. 12.8% of patients also had a reverse hill-sax lesion compared to 11.4% on arthroscopy. And both the sensitivity and specificity of MRI and MRA in detecting humeral bone loss was excellent. Again, there was no difference in the diagnostic accuracy. On imaging, glenoid cartilage lesions was identified in 9.9% of patients, whereas on arthroscopy, cartilage lesions were seen in 19% of patients. Most of the full thickness cartilage defects were in the posterior and posterior inferior regions of the glenoid. And on the humeral side, 13% of patients were found to have cartilage defects on imaging compared to 15% on arthroscopy. The sensitivities of MRI and MRA for detecting chondral lesions were poor, and again, there was no difference between modalities. It's important to interpret the findings of our study within the context of its limitations. The primary limitation of this study is that the images were read by a highly skilled, high-volume MSK radiologist, and these results may not be generalizable to community practices. The MRI protocols also differed among institutions. There was a slightly higher proportion of 3T MRIs compared to patients who had MRAs, but this was not significant. And lastly, the duration between imaging and surgery may have varied between modalities, but they were all within six months of surgery. In summary, there was no difference between MRI and MRA in patients with posterior shoulder instability, and it is also important to highlight that an arthrogram is an invasive, time-consuming, and costly procedure. To put things in perspective, the 2024 Medicare data shows that an MRI increases health care costs by 283%. As health care costs continue to increase, it's hard to justify the continuous of MR arthrograms in patients with posterior shoulder instability given little diagnostic benefit. I'd like to thank all of our contributing authors and research staff and funding sources who made this study possible. Thank you. All right, in our last paper of the session, Justin Arner is going to present on acromial morphology in primary versus revision posterior shoulder instability. All right, thank you everyone. I appreciate the opportunity to give this talk here and like to acknowledge my co-authors and AOSSM for the chance to give this talk. Our disclosures are not relevant but are not on the program. Posterior shoulder instability historically was thought to be quite rare. We talked at our ICL, Brett Owens had a great point that the surgery posterior instability is probably increasing, maybe incidence is not, but recent data has shown that surgery is happening more commonly. From our group, over 1,700 consecutive labral repairs, 65 involved the posterior labrum with about 20% being isolated posterior repairs. Duralde and Kibler had similar findings with 48% and 26% being isolated posterior repairs. The contribution of bony parameters to posterior instability has mostly been focused on the glenoid. Dr. Owens has taught us a lot about this and talked about the contribution of glenoid retroversion and bone loss and developing recurrent posterior shoulder instability. Our group, as well as Dr. Preventers and others, has shown decreased glenoid bone width leads to inferior surgical outcomes and increased revision rates. In 2019, Dr. Gerber introduced the thought of the posterior chromium, so kind of a first time we're really looking outside the glenoid. He measured four acromial parameters on a C-arm x-ray, lateral x-ray. You can see them here in the diagram, that posterior acromial coverage, posterior acromial height, tilt, and the anterior acromial coverage. Basically, he found that posterior instability was associated with a higher and a flatter acromion. So in 2023, with Drs. Preventer, Dr. Bradley, and Dr. Millett, we evaluated these same measures that Dr. Gerber described about an MRI, and we found similar findings that a higher and flatter posterior acromion was associated with posterior instability. Further, a 2023 study from Dr. Dickens' group, and there was also a presentation last year at AOSSM from their group, looking at these measures on MRI, and they found that a flatter and flatter acromion, we basically saw more and more posterior bone loss. So as you can see here, you get over 13.5%. Basically, you have a flatter acromion, so it seems like certainly something to this. So the purpose of our study was to evaluate the differences in acromial morphology between primary and revision arthroscopic posterior capsule labor repair. We hypothesized that a higher and flatter posterior acromion would lead to a greater risk of revision surgery. We included athletes of any level over 18 years of age who underwent arthroscopic revision, posterior capsule labor repair, and basically matched those to the non-revisions. We performed the same MRI measures at a previous publication, including anterior and posterior acromial coverage, posterior acromial height, and posterior acromial tilt. So you can see here in Dr. Gerber's nice picture on x-ray, I think it's easier to evaluate, but if you draw a line through the center of the inferior portion of the scapula, and then through the center of the glenoid, and then basically make your measures from there. So the posterior acromial coverage, you can see that angle in red, the posterior acromial height from that center point on the glenoid, and how high that basically that acromion is from the center point of the glenoid, and the tilt, you know, how flat it is basically, and then also the anterior coverage. We identified 37 revision posterior capsule labor repairs and matched those, as I mentioned, by age, sex, and sport to 37 non-revisions. Our MRI inter and intra relator reliability was substantial, almost perfect. We had two reviewers. When comparing the acromial measures, revision patients did have a higher acromion, on average 3.5 millimeters, so not the biggest difference, but there was a significant difference there with a higher acromion and those that failed surgery and required revision. The revision patients did have a higher and flatter acromion as well, but this didn't meet statistical significance. You can see the numbers there. Basically the acromion was flatter by about two degrees, again not significant, and approximately 10 degrees less posterior acromial coverage, as you can see in the pictures there from Dr. Gerber's manuscript. So limitations to our study used the, we didn't use reformatted MRIs. You know, Dr. Preventer has taught us, and we've done studies before using different types of programming where we can basically change the rotation of the MRI and maybe get a better and more accurate percent of bone loss, but I think this is more applicable to clinical practice. You know, will CT be better than MRI? Evaluating these measurements, we didn't have any patient reported outcomes to compare those. We had 37 revisions, but it's a substantial number, but greater power would certainly improve the study strength. In conclusion, a higher acromion was associated with requiring revision, arthroscopic posterior capsule lay repair. Posterior acromial tilt and coverage was not significantly different between the groups. You can see a nice diagram from Dr. Dickens' paper here just showing a higher acromion there on the right compared to the left. Prior studies have demonstrated a higher and flatter acromion may predispose patients to posterior shoulder instability and is associated with posterior glenoid bone loss. Our study adds that a higher acromion is associated with failure of arthroscopic repair and the need for revision. The clinical implications of this and what interventions can and should be performed are still to be determined. It's been discussed of acromial osteoidomy in Europe, and Dr. Owens did this nice study here, and we can talk about that. Basically taking a piece of bone from more medially on the spine and adding it to the more lateral portion of the acromion, so still to be determined. Thank you very much. Thank you. Great job. I would like to open up the mics to any questions. If anyone has one, I'd like to start for Dr. Feeley. Do you have a thought when you do over reduce the AC joint dislocations, do you see increased stiffness in those patients or an increased clavicle fracture or coracoid fracture as a result? Yeah, so in the similar cohort we've looked at fractures as a whole, and we did not find a distinct difference in terms of whether even drill holes were used or not. So there's some concern among surgeons that if you over stiffen while over reducing, you may increase that risk. We found previously that that really doesn't seem to be the case. you know, caution you when you publish it to really be thoughtful of the other things you might be missing in the author grant. I agree. Thank you so much for those comments. One for the AC joint paper again. Is there a reason not to over the reduce them? Like so, you know, gray hair 20 years, like it seems like the longer I do this the more I over reduce it knowing that it's probably gonna slip back to normal, but did you see well two questions, I guess. Did you see any over-reduction patients that stayed significantly over reduced? And two, did you find any problem with that little bit what what Sarah was getting at earlier? Right. So the major concern people cite when we brought this up is the concern about fracture. To your point about the whether they maintain reduction. So looking at the patients that were over reduced compared to those that weren't, the amount that they lost reduction by tended to be similar. So you could kind of expect the same amount of elevation to occur post-operatively in either group. Now what we don't know because of the retrospective nature is whether the patients that are over reduced are able to be reduced by more and that's what's affecting their outcome. Or if it's actually the over reduction itself that is helping their overall loss of production. All right, and I have a question for Dr. Arner. In your paper so we talk about the morphology of the acromion and it seems very drastic to me that I've heard Christian talk about doing an osteotomy and changing the whole body, but you know how common is the problem and that you would need to go to that extreme, I guess, you know, it seems. Yeah. And what's the hypothesis of why that is? Is the acromion somehow keeping the shoulder better in place or is it the whole anatomy is different? They have less retroversion because of that? Yeah, it's a great question. I don't think we know all the answers to that. But you're right. I think arthroscopic repair posterior instability is very successful. You know, Dr. Bradley's group 6.8% I think revision rate. So I think diagnosis is the most important thing with that. So I think certainly, I haven't and I don't think I ever will do a acromial osteotomy, you know from the reverse literature. It's a different pathology, but such a small bone and not a insignificant incision and approach and I think Dr. Owens bringing this technique back is an interesting one. Taking the spine more medial, I think it was described in the early 2000s and putting a bone block more laterally is interesting, you know, I don't think that it's that common of an issue like you mentioned. I think arthroscopic repair is quite successful, but it's an interesting thought that he's brought up. I think that you're probably right and I think that what Dr. Dickens taught us with his recent study in the fall from JSCS looking at bone loss posteriorly, I think with the acromion possibly being flatter, maybe that you get this subtle repetitive and more commonly posterior subluxation, if you know, causes posterior labral tearing and just over time you get that attritional bone loss in the glenoid. So I think that probably tells us that maybe that's where it's why it's happening as you mentioned. It's interesting though. So I can't let Dr. Morrissey get away without having a question, so I learned that from Chuck Bush-Joseph, so so you showed that two anchors is actually a more stable or less resistant construct, but then at the end you threw out maybe we just need one because it gets you back to baseline. So for those of us that are gonna go do remplissage on Monday, should we do two? I mean, there was also this theoretic. Well, maybe two, it's more resistance, less, more resistance to translation, but maybe that leads to stiffness. So that's a little bit of a leap. But I think most people that are doing this are using two. Tell us why we shouldn't or tell us what you're gonna do on Monday. Yeah, so I mean I'd say one is enough because in all anchor locations that we looked at and in the two different size lesions, you were able to restore native stability with just one. And then in the large hillsacks condition, two anchors ended up giving you more stability than the native or intact condition, which I don't think you should really need. Thank you, speakers. OK, so we're going to have three awesome demos here. First up is Julie Bishop from Ohio State, who's going to talk to us about remplissage. Okay. All right. Well, it's great to be here. Thanks for having me. And here are my disclosures. So, I think we all have to realize that there's a lot of factors that are not in our control when we're treating the instability patient, but technical aspects are, and how we do the surgery is in our control. And it matters because the failure rates are high, especially in the young contact athlete. And so, everything starts with a proper setup for success. So, you need to do, first of all, what works in your hands, lateral or beach chair. I won't make fun of Dr. Wolf because he's unenlightened for his beach chair. You need to get low. That's what you have to do. Be there for the setup. And for the short people, the lateral position lets you work with your hands down at your waist. Tall people like my partner don't know what it's like for us short people. So, that's one of the reasons I like lateral as well. Lateral's the way for me. I prep the arm with the finger traps on the other side of the bed because the underneath shoulder can roll towards anesthesia. If you don't do that, changing the position of the scapula and really making you struggle. Your portals are important. Be precise. Make the shoulder a pin cushion until you get it right because it will pay off. I localize the spinal needle. I then use a switching stick to make sure I can get there, then a dilator in my cannula. Outside of the body, keep the cannulas far apart so they're not dueling, but inside you can be close. But just think about it, if your switching stick and spinal needle can't get there, your anchor and your trocar can't get there. So, take that time. Know the portals and the different portals to use. Number one is your posterior viewing portal and number three is percutaneous if you do that posterior inferior anchor or it's very close for where you do your remplissage percutaneous portals. Anteriorly, five is obviously you're working and you can view from anterior. Anterior superior is really important to look down on the face of the glenoid. I don't do trans subscap, it's too scary, I'm a fraidy cat, but I think you can get there without that portal, but if you can do it, know the neurovascular structures and where they are. First thing you have to make sure, I put the cannula anterior superior, I look down and evaluate the entire labrum. Don't miss that posterior extension. Start with the liberator very carefully, start to free up the adhesions. Don't slip and radially split out through the labrum and then when you bring your shaver in, try not to remove too much bone. And as you progress, this is what you wanna see. You have a medialized labrum that you've now completely mobilized, it floats up to the glenoid, there are no adhesions between it and the glenoid and you can see those subscap fibers. That is properly prepared because now you can shift it. If you don't do that, you're going to be doing a repair in situ which is not going to benefit your patient. If I don't do remplisage, I do a posterior inferior anchor, you can see we've already prepped the bank guard in the front, we percutaneously place the anchor, you can lever against the head with your trocar to get that and I start my shift there and then I start to work away, work around and up the front. But we're here talking about remplisage because I think it's important and I think it's really here to stay and I think Peter McDonald's paper is one of the best papers that have shown us that remplisage will decrease your recurrence rate and decrease your revision rate. So I think you need to go to surgery knowing how to do it. And you have to know the order. So again, if I'm doing remplisage, I don't do that posterior inferior anchor because I think it's just too much suture dueling. I do the diagnostic scope, make the portals, I mobilize the labrum and I prepare the glenoid. Then I go up and prepare the hill sacks, I place my anchors, sutures, I don't tie and then go back down and finish the bank art and then go back up and tie or shuttle whatever method you're going to do your remplisage. And if you're doing the remplisage in beach chair, I think it's a little easier to get to the hill sacks. Sometimes I'll do a remplisage with a latter J and I can tell it's easier. But in lateral, if you lower that abduction boom and I'll show you that in the video, it's actually a lot easier to get to the hill sacks and makes it not as difficult. So here we've prepared the labrum and I'm bringing my camera around and you can see it's kind of hard to get up there. I'm kind of levering against the head and now we release, we don't take it out but we just release the traction. I push the arm down in adduction and I bring the camera up and it's so much easier to get there. This was life-changing for me when I learned this. My cannula now gets my shaver there easily. You've got to prepare the whole hill sacks. Then around that seven o'clock anchor, percutaneously localize where you want to be. Your cannula, you're sweeping it extra capsular so there's no muscle. And then when you pierce through that cannula, if you have a sharp device like I do, you've got to push it down for the inferior one and push it up so you don't jam that into the humeral head. And again, your anchor position is important as the paper showed. Closer to the humeral head, you're going to tether more tissue in. Further away, closer to the footprint, less. So I have nice two anchors there and this is showing outside of the body where a finely oiled machine. I'm holding the cannula, my assistant is taking the drill and everyone's engaged so you're moving nice and smooth and I'll come back to that suture management for these sutures. And then you come back around and now you're ready. You put that arm back up in traction and you are ready to now repair your labrum. And so now this is just a little closeup. I use, now I shuttle. I used to tie, it's a nightmare. I don't do it anymore. I use the shuttling knotless and I put two snaps right up at the face of the cannula so I don't tangle those sutures. And then you're prepared your labrum and you get low. There's some cannulas that let you, that are curved that can help you get there but you get as low as you can and you put your first anchor in and I now have gone to all suture. And remember, you've got to pull that labrum up when you tighten. You don't want to have labrum bunched below in your anchors and you keep doing that. And then I'll retrieve the bottom suture and look at that. I've got a little more that I've tensioned and shifted and you keep working your way up. I cut the lower one as I go, take a nice bite of the capsule and you keep again shifting every single time. Have someone through your accessory portal grab that labrum and capsule and pull it up so you're continually shifting. And then this is a nice technique to park that suture that you're going to retighten. I put the switching stick in, pull the cannula out, pull that suture out and push it back down so I'm not tangling that one. I'm gonna go back and retighten. And I have a five anchor repair. Remember, at least three anchors below the equator. And then we come back up, we take the arm back out of traction and then outside we're shuttling those sutures and we're just going back and forth, tethering that tissue down into our defect. And then here's outside, one person's holding the suture. I grab it and I just go back and forth and I watch inside until I feel like I've really got this tissue all the way down. And then here's our repair, our head is centered, our remplissage is complete and we've had a nice smooth surgery. So thank you. Thanks, Julie. Now we're moving on to Lyle Cain on posterior labral success. Thank you. I'm going to show you a few of the same general keys. I like, it's nice when people are consistent, right? We have the same kind of general thoughts. We're going to talk about keys to success and posterior labral repair. So some general thoughts. I prefer the all suture knotless permanent anchors. You know, for many years we used the biodegradable. We saw a lot of this. We'd go back to scope of shoulder. The suture is still tied around the labrum, but the anchor had resorbed. And so you had no more fixation. I think many of these tears end up spot welding at the anchors, rather than having complete repair or healing. And so I think it's nice to have something permanent that's always there. I think in general, more anchors are better than less. There have been several studies looking at this. Original study, Pasquale Below, showed that less than four suture anchors was an independent risk factor for failure after a labral repair. So I think more anchors in general are better. But the more anchors you use probably increases your fracture risk. This is, I think, the most common mechanism of failure for most labral repairs now. You know, we have super sutures, super anchors, very strong materials. But the more holes you drill in the glenoid, the more likely this is to fracture like a postage stamp tears through the serrations. So I think you have to be careful with that. And therefore, smaller anchors are better. So I think when you look at the traditional three millimeter or 3.5 millimeter anchors we used to use, compared to the 1.8s, there's 74% less bone loss by going smaller with the anchor, which would give you less risk of glenoid rim fractures. So my preferred technique, I typically like to do an anchor at every hour on the clock face, which is, you know, it could be a lot of anchors depending on your tear. At the inferior capsule, I like a horizontal mattress. Peter Millett has shown a nice study that horizontal mattress actually gives you better labral biomechanics. It keeps the labrum from rolling off the glenoid when you take traction off. But it looks terrible because you see the bottom of the tear and it looks like a torn labrum. So I'll start at the bottom with a horizontal mattress, and then I'll alternate simple sutures up. Once I'm above the equator, I do all simple because it's not as likely to roll off when you let traction off. So this is a case example of a 22-year-old PGA golfer, six-month history of left shoulder posterior instability. He tried to play through it, but he really couldn't hit his driver. Every time he hit his driver, his shoulder slipped out the back, and he couldn't compete anymore. So he came to me for a posterior labral tear. It's just in the MRI. So I think key number one is that you have to have an accessory posterior portal for posterior lever repair. This is viewing from the anterior portal. Your typical posterior entry portal is too horizontal to the glenoid. You really have to put a portal that's about 45 degrees off the horizontal. So you want something that you can get good leverage, aim towards the center of the glenoid, not skive off. It's really nice with these curved drill guides because you can kind of turn the drill guide towards the center of the glenoids. When I'm down low, I'm facing more superior. When I'm up high, I'm facing more inferior and it allows you to face towards the center of the glenoid and have better purchase. Key number two is that you have to prepare the posterior glenoid. That's really hard from the posterior portal. I've watched fellows my whole life, 25 years now, and I'll tell them this and then I'm watching them prepare and they're struggling, they can't get the shaver to hit the bone, they're trying to shave it, they're shaving through the labrum. And I think the key is you can go high and shave the bone, but right at the portal, there's a window there that you can't really get to. Some people use a rasp or a burr with no sheath, but it's really easy if you just come from the other side. So you put your scope in your accessory posterior portal that you just established. You've got a nice gestalt view from the top, way up high in the sky, and you can watch the base of your shaver blade and you can shave that posterior glenoid and get a nice bleeding bone bed, which you can't do very well from the posterior portal. So you're able to start and you can kind of slip up under the labrum. You can use an elevator to elevate it more, but usually it'll kind of pop up over you like that. Key number three is consistent anchor placement. I think how you put these anchors in, every anchor's different. These soft knotless anchors, you really don't have to hit very hard. So I cycle the little night and all drill bit and I put them in by hand. I don't like to hit them with a hammer. I like to use all inside suture passage. I think it takes some of the complicating factors of suture passage out of the equation. So I use one of these lasso type devices through my regular posterior portal. Coming in a little more horizontal, I grab a nice bite of capsule and then I come out at the glenoid labral junction. And what this does is it keeps you from having to shuttle in and out of cannulas. I do these without a cannula. I know that's not common, but I think once you learn your kind of your orientation, your triangulation, it's easy to get in and out of the same hole and you probably make less of a capsule hole by doing everything through a single stab wound rather than a big cannula. Key number five for me is to keep the converted repair stitch for additional tensioning. Julie showed that where you convert the first suture, your second anchor is pulled down, converted. You can go back to the first one and get a little extra tension. These devices are kind of tensionable, cyclable. So you cycle them a few times. If you sit there for two or three minutes, you can actually cycle it one or two more times, get some more tension and probably take some of the slack out of the system. So I like to keep my sutures in until all the anchors are passed. Then I'll sequentially re-tension each one then cut the sutures. Key number six is to put anchors at every hour on the clock face. Again, a lot of anchors, but when you're using 1.8 anchors, it's not a lot of holes in the glenoid really from a size standpoint. Key number seven, I like to balance the inferior capsule. I know Julie showed this as well. For every posterior labral tear that goes down to six o'clock, I'll put an anchor anterior inferior because I think you have to balance the hammock of the glenoid inferior capsule. If you just have everything around the back and you leave the front un-tensioned, I think it changes the balance of the shoulder capsule and may allow propagation of that tear around the anterior inferior margin. Key number eight, this mattress suture I'm talking about, there's a lot of ways to do this. I've done it by passing the repair stitch first and then passing the second stitch from glenoid to labrum or glenoid to capsule. The way I do it currently is I like to pass the repair stitch initially, normally from the glenoid to the capsular side. And then I'll reach in about a centimeter away and then I'll grab the conversion stitch, which is the round stitch for this particular type of anchor. I'll grab the round stitch through the second hole. And then when I convert this, it makes a nice mattress suture where you pull the labrum up on the glenoid. And it really, if you look at it biomechanically in cross section, it really pulls the labrum up and keeps it from rolling off the labrum, off the glenoid. So that's a mattress suture. I think it's also important with posterior lesions, especially isolated posterior instability to close the posterior capsular defect. We've been doing this for 20 years or more. The hip arthroscopy people have really shown us a lot about this. I don't think this has been studied much in our literature, but in the hip, they close all the capsules now, especially for instability. I think it makes sense not to leave a vented shoulder. Really simple ways to do this. I just use a typical bird beak. There are other measures you can use, other devices, but just a simple suture to close the portal, I think takes a lot of the slack out of the capsule. So in conclusion, these are kind of the nine keys to success for labor repair. I think once you get your triangulation technique down, if you'll think of these as you're doing your cases, it'll really make it a lot smoother procedure. Thank you very much. All right, now we have Dr. Brian Waterman from Wake Forest gonna talk to us about AC joint management. Thanks. All right, great topics, and I love this session. We're gonna talk a little bit about AC joint injuries and how we might address that surgically and when my disclosures can be found online. Dr. Codman alluded to one of our defining features as humans is our presence of our clavicles. And certainly these can sometimes get in the way as we engage in athletic activity. Wait for it. There you go. And you can see these AC joint injuries, if we've seen them in the office, can be quite painful and somewhat difficult to manage. These are all the variables that you need to really consider as you address these among your patients. And we know this grid that looks at the extent and spectrum of injury across AC joint injuries. And for our purposes, we're gonna largely focus on the type three and above. And to really get a full appreciation of this, we need to look at an extensive radiographic workup, including this cross-body adduction view, which allows you to elucidate those type three Bs, which we know can be relatively bad actors according to this Isikos consensus statement. And that's where you have bayonet apposition of the end of the collarbone over top of the acromion. And in terms of ideal management, I think it's hard to establish consensus. You can see seldom do two orthopedic surgeons agree on the precise management of complete AC joint dislocation. 1962, so not much has changed. We do appreciate the spectrum of injury, though, even more. You can see with these high-grade injuries, you can see rates of associated intra or pericapsular injuries of the shoulder up to 40% of the time. So definitely you wanna do a nuanced exam and engage in advanced imaging where appropriate in order to find that, or routine arthroscopy prior to your technique. Additionally, Ben Kibler, as in many things, has emphasized the importance of the scapula in determining success. You can see rates of dyskinesis is present in 73% of those high-grade injuries. This can lead to spinning out of the scapula, and it can both, A, doom you to failure with non-operative treatment, and B, really compromise your strength of fixation. So for me, we really try to uncouple these two to promote a broader chest in order to bring the clavicle out to length and really emphasize abduction, retraction, external rotation, using a number of different bracing options. The byproduct that is, however, we often miss our window for repair. This is ideally performed within the first two to three weeks. This can be both open and arthroscopic, button-based, plate. There's a lot of different options, but unfortunately, as was alluded to in our presentations, certainly we have to cheat the system and over-reduce it in order to maintain a reduction. And the rates of reoperation are not uncommon, 40% with loss of reduction. There's been attempts to try to remedy that with separate fixation on the AC joint, but loss of reduction is common. And you can see you have a 3.1-fold higher rate of loss of reduction if you just achieve anatomic reduction. And so you really need to address both of these and make sure that you're addressing your injury patterns comprehensively. So the big question is, does a delay in diagnosis or treatment, does it matter? I think no, as long as you're performing the right procedure once you've gotten out that critical two- to three-week window. And Peter Millett has certainly advanced our knowledge base on this. You can see those individuals with type three and above with a trial of conservative management, no difference if they got to the OR later. J.T. Tokish has also suggested that these type fives may also be candidates for non-operative care. You know, these are the ear ticklers you see in training room, but you can see in his series, 61% return to duty without surgery. So quite impressive. Unfortunately, as you get to techniques, we probably need more than seven minutes to discuss it because 130 techniques, there's only one area where that's more common, and that's bunion surgery. We know how successful that is. About the distal clavicle, we know that the distal end really has an important stabilizing effect. So I would encourage you, unless it's blocking reduction, don't resect that distal clavicle. So this is an illustrative case. This is a 3B that walks into our office. Believe it or not, he is a grave digger, and this is his dominant side, has persistent pain that persists after four or five weeks. And so my technique has been to use a graft, also a synthetic augment, and we'll just walk through the individual steps. You can see it's a lazy beach chair position. I'll arthroscopically evaluate and treat any associated pathology. I'll clear out the rotator interval, and I'll facilitate my passage by clearing that out. But then I really take my keys from Gus Mazzocca. I think this is an open-end procedure, and that's a vastly different operation. So I performed a medial-to-lateral incision, and then we'll just go ahead and get down to the coracoid, establish our windows on either side. You have several different guides, or you have vascular clamps, and you want to obtain passage on either side and pass that shuttling suture. At that point in time, you have the option for drilling a clavicle. We've certainly seen the risks for clavicle fractures with this. If you have a contact athlete or an individual of small stature where you're more concerned about there being a fracture, then you can certainly just do a wrapping technique and bypass this completely. But in these individuals, I do prefer it, and we'll use interference screw fixation. Then we go with our graft and cerclage passage. I think my goal is to not drill the coracoid. I've seen way too many fractures. This has definitely been an issue for me, and I'd love to be able to avoid and bypass the bony problems altogether. So you can see our grafts getting passed through the tunnel and then our cerclage around the clavicle, and then we're going to subsequently re-tension it. To your point, we're going to certainly try to achieve a little bit more than anatomic reduction, knowing that our internal splint will gradually loosen over time. At that point in time, then we just perform our fixation of our interference screw, first starting on the clavicle, and then removing all the slack from the system, taking it over laterally, and then fixating in our acromion. I prefer an all-suture anchor that was alluded to in our prior talks, and that helps to create an on-lay fixation, and then you can wrap that graft back onto itself and really nicely reconstitute that capsule while reinforcing the native tissue over top of that. This is not a new idea. I learned this from Brett Owens, who was in the audience just previously, and he certainly encouraged me to address that acromial limb in order to make sure we have more reproducible outcomes, and he's described this technique using a socket-based technique in the acromion. It's also important that if we are drilling tunnels, we need to make sure that these are in the appropriate position, so this Rios article has been very helpful for making sure that we're not treating Julie Bishop the same way as Brian Wolfe and trying to make sure that our measurements are relative to the length of the clavicle, which hopefully we've done here. In terms of recovery, we go slow. We immobilize. We're allowing things to scar and unheal. We'll get our motion later. These individuals do not get stiff, and then we anticipate return to sport, in this case, grave digging, at four to six months after surgery. Again, Mazaca pearls cannot be underemphasized. I show these here. Do not oversize those sockets, and make sure you go slow with the rehab. In conclusion, you need to identify and aggressively treat concomitant pathology, which can be present in up to 40% of the population. Scapular dyskinesis needs to be unpacked, and make sure we're appreciating that horizontal instability. Early CC repair is an option. It's ideally suited in the first two weeks, but overreduction is necessary, and loss of fixation and secondary complications can occur, and when choosing an option, I think a biologic and synthetic combination is ideal, but it's got to be anatomic for more consistent clinical and radiographic results. Thank you. All right, thank you for all of those. Bob, you want to come up? I think Bob, Dr. Arciero is on our panel as well to go over some cases. Do we have any questions before we do that for the, about the techniques? Okay. You can go for it. Okay. Okay, well, Sarah and I put together some cases. We have about 10 minutes. We'll try to get through a couple, hopefully. We have an awesome panel here. So, Bob Arciero, kind of the guru of shoulder surgery from UConn, and then we have the football powers of Ohio State and Alabama here with Julie and Lyle, and Brian from Wake Forest, so thanks for that. We're gonna try to give you some cases that are hopefully interesting for everybody. So, this is one of our Iowa players, 22-year-old redshirt junior, D1, defensive tackle. He's about three bills. He injured his shoulder in the second game of the season, had a grade three AC injury. After a week or two, he was able to return, but he needed some help on game days, complaining of a lot of pain and clicking. He's actually not been able to sleep very normally from the second half of the season. On his exam, we're now in January, so he's gotten through the year. He's played on Saturdays. He hasn't practiced much, and he's still complaining quite a bit about his shoulder. He's got full range of motion, but he's got pain overhead. He's got a tender AC joint. He's got huge traps, but you can tell there's a deformity there. He's got some crepitus. He also has some glenohumeral posterior joint line tenderness, and he has some pain with labral tests. He has no instability, but he has pain on jerk testing, and he has a positive O'Brien's test. So, here's his original x-rays on the left. So, it's his left shoulder. That was in September. You can see his contralateral side. Here we are in January, so it really hasn't moved a whole lot, but we note he's got a fair amount of HO sitting right below his clavicle. Does have an osacromialy. So, here's his advanced imaging. So he's still got quite a bit of fluid around his AC joint. He has a slap tear, posterior labral tear, maybe a little bit of a reverse GLAD lesion. We're in January. He's a kid that has possibilities for a career after college. He's got a grade three AC joint with some HO, slap posterior labrum. I've gone a long time taking care of college football and tried to really not treat AC joints if I can avoid it. But with this kid, treat the labrum, treat his AC joint, treat both. If you take care of his AC joint, how would you do it? Is it different because he's a football D tackle? And what are you gonna tell the coach about when he'll be back? So why don't we start with our esteemed back Dr. Arciera at the end. Nice easy case there, Brian. I'll tell you what, I think it's obvious that this young athlete has two very significant pathoanatomic problems. But to sort out which one or if both are symptomatic, I might do a selective injection at separate times. Inject his AC joint area and see what kind of pain relief you got, symptom relief you got. And then inject his glenohumeral joint. And I think if you can implicate that both are really significant issues, then I would treat both. I'm gonna just stop there. Okay, I'll move, let's go, Brian, thoughts? You know, I'm gonna try to ignore that AC joint as much as possible. I will pad it, I will create a custom brace for it, but trying not to touch it at this juncture is probably our best pathway forward. And then I think we know from our exam studies is that posterior labrum tears often present which is pain alone. So it's a fairly nonspecific finding. So I'd chase that labrum and probably would pursue coverage of that GLAD lesion. Lyle? Yeah, I think, I mean, it sounds like he's four months out now, he still has pain that affects sleep and other functional things. It's probably AC joint related from your description. It sounds like you injected his AC joint during the season to get him through. So I suspect he's got some AC joint pain that's affecting his performance. So I think, you know, if I'm gonna fix this guy, I think you gotta fix both. I think if you fix his AC joint, do a reconstruction, get through the process, then he has deep posterior shoulder pain, you're kicking yourself. If you fix his labrum and leave his AC joint alone, the next season you're having to inject his AC joint all season, I think you're kicking yourself. So I think I'd fix both of them. Julie, any different thoughts? I think the only thing I would add, I would just wonder on his exam, how unstable is his AC joint? You know, people with a lot of grade fives, you know, no HO, you can push it up and down. It's very unstable. But with the HO, did that stabilize it at all? Yeah, great points. No, I didn't get a lot of movement. Again, he's a hard exam. He's 5'10", 3'10". I mean, he's like typical Iowa D tackle. We don't get the six, four guys that go to Bama or Ohio State. We get the 5'10", you know, pluggers, you know? So I don't think there was a whole lot of movement. But I do think the HO was, I think, symptom. I've just seen that. I think once they get a lot of HO, I think that can cause some pain. He did have posterior shoulder pain. He didn't have instability. I didn't do an injection. I think that's a great idea. If you're gonna fix it, when are you gonna tell them they're back? Lyle? I mean, I think the AC joint, as we've shown in the papers today, and I think we all know, tend to stretch out over time. So I'm a little bit conservative with those. But the truth is, a D-line over the posterior labral tear is probably a four or five-month process anyway. So I think the time courses are pretty similar, and that's why I think fixing both at the same time probably makes sense. You know, I would tell the coaches, it's January. He's not gonna do anything in spring practice. He won't do much during the summer except lift and get back in shape. But by August, he should be okay. So we only have a couple minutes. I wanna make sure Sarah gets another case up. But if you do a contact athlete with an AC joint, is anybody drilling the clavicle? Drilling, gonna make tunnels through the clavicle. Yeah, I throw everything I have at it because I think it's gonna stretch out anyway. So this is probably more aggressive than anybody up here, but I do a graft. I'll take their own gracilis, usually do the typical CC reconstruction that Bob and Gus and everybody showed us how to do. I'll wrap that with a nine-stranded absorbable suture, like a PDS, around the coracoid for backup fixation. And if I'm really concerned about it, I'll add in a suspension refixation too. I'll triple cover because these things are gonna stretch out. Even with three things, they'll stretch out. So with anything by itself at four months, I think you're gonna stretch out. Anybody else have any other pearls that they would do on a football player? We've been, we've had good luck at, I know I'm not on the panel, but we've had good luck just using and wrapping it around. My partner, Alan Zhang, wrote up the technique where you take the surplus wire that's used for fractures, but actually just cinch it over the clavicle with no tunnels. And it works great. You can over-reduce it, as we discussed earlier. And no risk of breaking through the clavicle. Yeah, I mean, we're all very fearful and collision athletes of a post-operative fracture. You actually, and I kind of agree with Lyle, you don't have to make a very big tunnel. You can make a four, four and a half millimeter tunnel and use the gracilis. And we tend not to use the gracilis, but we actually did a biomechanical paper and we published it in AJSM that the gracilis was every bit in any parameter that you measured, ultimate load and cyclic loading with gracilis versus semi-T. So, and it gives you the advantage of drilling a tunnel, but a small one. And I would only use one. So, Gus and I disagree. He, you know, his classic technique is totally anatomic, but I worry, you know, a football player who has to hit people every single play that we're going to get a fracture. And I would also do the AC joint. I mean, swing a limb over and much like Brian showed, very, very similar. And I would, and use a suspensory synthetic, I don't want to call it suspensory, but additional fixation. Okay. Well, here's one additional comment. So, I do the same thing with the AC joint. This guy's got that osteochromialia, which makes me nervous as hell, because if you take the graft across to the front of the chromium and you tension it, you're probably going to flex that os down, which is a problem too. So, in this guy, I'm not sure I would do that just because of his os. So, here's what we did. We just, you know, I was just going to take care of everything. I just had nightmares of this guy hurting if we didn't deal with both. And he's a pretty straightforward kid. So, he had a bad slap that we cleaned up. We fixed his posterior labrum. So, we did a, I use a semi-T typically. So, I do a double wrap, kind of wrap it around their coracoid and around their clavicle. I would put those through tunnels typically, but since he was making me nervous, we wrapped it around his clavicle twice. I would also usually try to swing some tissue to his AC joint, but because of the os, we didn't do that. So, we over reduced him. He did kind of merge back a few millimeters there at three or four months. He got back to play at about four and a half to five months. Hey Brian, talk to me about bushwhacking that HO out and then also any prophylaxis on the back end because that's a very humbling part of the procedure, open or arthroscopic. Yeah, great question. So, we actually published a little case series, Robbie Westerman, who's now one of my partners. I had a series of about four or five of these patients several years ago where we had all this HO and I got in there and got burned because it's not always where you think it will be. It's not fun. It tends to go very medial. It can also go posteriorly into your cuff. So, it can be very, when you start to get real medial, you'll start to get nervous because you're in the tiger territory. So, whenever there's a lot of HO, I've actually, I didn't get it in this case, but it could be useful to get a CT scan, even 3D reconstruction, know where you're gonna go digging. But carving that out is, I think, super helpful. You probably can't reduce the joint normally unless you get it out of there. One more quick point I learned from Jim Andrews. Once you do one of these, if you want to keep your sanity, don't ever X-ray him again for any reason, no matter what they say. Especially if they're big traps because you can't tell them apart. That's an Andrewsism. I don't X-ray him. Don't X-ray him. All right, we're over time now. Any last minute questions by anyone for the panel? Yeah, that's good. I can do another one if you want. I don't know. You have time? All right, I'll run through one more. It's a simple case. Okay, good. This is an easier case than what Brian showed. So, this is a 19-year-old collegiate rugby player who presented a cheek complaint of a shoulder dislocation. First time during practice. Out for about five minutes. Was reduced by the athletic trainer on the field. Was neurovascularly intact. These are his X-rays that I got. Nothing really significant other than osacromial that showed up on there. And his imaging studies, you can see large anterior labral tear, medium to small hill sacs, and then maybe a subtle suggestion of a tiny bony bank heart lesion. Julie, any thoughts about this young man? I mean, I think he's a rugby player. My sense is that most rugby players are going to want to keep playing rugby. So, it's going to be very hard to tell him that you should have surgery right now. And honestly, if he said he wanted to have surgery right now I would be concerned that a bank heart and a remplisage would still fail. So, I would probably counsel him that he is probably going to have surgery at some point. If he keeps playing, he is going to lose bone. That's going to increase his risk of arthritis down the road. So, that's one bad side of having bone loss, even though we can fix it with a Latter-day. But ultimately, I am going for a more aggressive surgery in this guy. So, if he wanted to keep playing, I would let him. But I'd probably say after the second one, you should stop for the long-term health of your shoulder. Right, that's great. So, we had that discussion about surgery or not. He chose to keep playing. He was offered surgery at that point. He chose to keep playing. He was the MVP of the national championship game for the US. He did experience periodic subluxations throughout the season, but no frank dislocations. So, it's the end of the season now. Lyle, what surgery are you going to do? Can we see any more imaging? No, no more imaging right now. No more imaging. Yeah, I mean, I agree with Julie. I think arthroscopic bank heart, remplisage is kind of the go-to for most of these athletes. I think a rugby athlete is one of those special people that you would think more about either an open bank heart or a bone procedure. I would go into the procedure with him and his family and his understanding that I was a scope to shoulder. If his bone loss didn't look significant, which I would say is maybe, in this guy, 10%, then I may do an arthroscopic bank heart, remplisage. If it looks like it's more than 10%, I'm probably doing a Laterge. All right, anyone going to offer him an open as a first-line procedure? Open, there we go. Okay, we got some guys, there we go. I was curious, anyone on the panel? All right, anyone to go straight to a Laterge? No, okay. So, I did an arthroscopic procedure. Now, when I went back in and looked at his shoulder, you can see he's got extension up into the superior labrum and this is his bicep tendon that is split. So, maybe the delay in his operation helped contribute to that. So, ended up doing an arthroscopic bank heart and open subpec bicep tenodesis. I did this case several years ago. So, at the time, now I would do a remplisage. At the time, I wasn't doing much rempli, any remplisages, but I would do, at that point, I did an arthroscopic bank heart and bicep tenodesis. He went on to make the U.S. national team, Olympic team, play professional rugby. He's had no further dislocations, so he did well. That means you did the right thing. Yeah, simple. All right, so we're out of time. We have 10 cases, Grover, I wish we could do them. Thank you so much, everybody, for coming. Just a reminder to fill out your evaluations. So, this year, what's different with the meeting is you can't really get your CME until you fill out your evaluation. So, make sure all the sessions that you've attended during the meeting, that you fill out your CME questions. And I really appreciate you coming. Can I make just one real quick comment? Yeah. So, when you let that, I mean, we all let our patients complete the season. You know, we give them the information. But if they have a lot of instability events, I'd get a CT scan before you take them to the OR, because it's amazing how much more additional bone loss there can be, just letting them play four or five more months. Yeah, that's a great point. We've all been there where you get in there, you're like, oh man, look what happened. So, thank you, everybody. All right, thank you, everyone. Thank you.

Sara L. Edwards, MD

Brian R. Wolf, MD, MS

Scott Feeley, MD

Patrick Morrissey, MD

Favian Su, MD

Justin W. Arner, MD

Julie Bishop, MD

E. Lyle Cain, MD

Brian R. Waterman, MD

Robert A. Arciero, MD

Shoulder Injuries

AC Joint Dislocations

Remplissage Techniques

Posterior Shoulder Instability

Scott Feely

Patrick Morrissey

Shoulder Arthroscopy

Labral Repairs

Scapular Dyskinesis

Surgical Reconstructions