We're going to start, his presentation still needs to be loaded. So what we're going to do in the interest of time is we're going to start with questions and luckily Dr. Kelly is prepared to grill the panel and I'm going to go ahead and pull the audience questions. Go ahead Summer, go ahead. For Dr. Smart, I'm just curious how there's a really large percentage of patients who were identified as having scoliosis proteric uptares that did not go on to surgery, do you know the rationale? Well, so the vast majority of patients, there was only 25 of the 47 that underwent operative intervention within three months of the initial event and so the vast majority of patients underwent PT, physical therapy rehab, and the number one indication for rotator cuff repair was pain. And so as long as even with these full thickness rotator cuff tears, if after long-term physical therapy they were doing well from a pain standpoint, most surgeons decided not to operate. Along those lines, and I'm trying to share the gray hairs here with the audience if it helps, but Dr. Smart, it's amazing the value of concavity compression, how cuff tears really do compromise stability. I was a little surprised that you didn't see more subscapularis tears there. Some articles purport a much higher instance, any comment on that? You know, I believe that isolated subscap tears in this population, it was a very small percentage. It was in between, I think it was about 2 to 7 percent. So again, it was really that posterior superior rotator cuff that we saw that was most commonly injured with these shoulder dislocations. I would also, I would add to that, I think that, you know, if we look, this cohort goes back to 94, 1994 too, so there were, you know, we weren't performing as many MRIs at that time and I think people weren't as acutely aware of the value or importance of the subscap on the MRI there at that time as well. So I think we've paid more and more attention to the subscap over the last decade or so. And so I bet if we did the same study, you know, going forward for the next 30 years, we would probably see much more attention paid to the subscapularis. I have two cookies here, but I've got to defer to my mentor, Dr. Bergfeld. So I wanted to ask the panel, in these older patients with dislocations, what was the mechanism of injury and what caused the injury and if it was a trip, why did they trip? That's a great question. The vast majority were a trauma, so some sort of probably fall onto an outstretched arm. It was one acute inciting event. I don't, I didn't have, we didn't obtain that data as to why the patients fell, if there was a medical reason, if there was, you know, some sort of heart or anything like that. But I did the vast majority of the data analysis looking through all of the charts and most of it was purely mechanical. So I don't remember any of the ones that I looked at that it was a stroke, a heart attack or anything like that. You know, something that actually got brought up by one of the reviewers for this paper was that maybe there's a higher percentage in Minnesota because of the ice, the snow, things like that, that definitely does occur in this geographic area compared to in the south. But that's not something, again, I've specifically looked at. So I have a quick question from the audience. This is for Dr. Mori and certainly the other panel would be interested in you weighing in. But, you know, the question is, obviously your findings are very interesting, but since we can't biopsy the rotator cuff as part of the preoperative workup, do you have a recommendation for how we address these older patients? Is your recommendation that maybe patients over 80 should all get reversed because they probably have cuff disease, even if they just have arthritis on x-ray? If so, you know, why do you recommend that and what about embracing convertible implants? Do you think we should just be doing an anatomic but planning that they're going to need revision to reverse for cuff dysfunction in 5 to 15 years? This is a difficult problem, but so in my opinion, RSA is so big because of advanced technology and so outcome is so excellent compared to the previous age. So I recommend reverse shoulder arthroplasty, especially for the active patient. So you actually recommend reverse for the active patient because you just anticipate that the cuff is going to... Even if the age is young. Yeah. Well, I'm sure, I don't know if anyone on the panel has any other opinions or anything else they'd like to chime in as far as that goes. The one thing I would add is I think that I'm generally for shoulder arthroplasty a fan of CT for imaging, but I think if there's a question, MRI can be immensely helpful. And we saw earlier today a beautiful slide of a thigh MRI of a 40 year old, a non-active 70 year old and an active 70 year old. And I think that if you get a shoulder MRI and that 70 year old triathlete's rotator cuff looks like their thigh muscles, then they may be a candidate for an anatomic. And I've done them in patients as old as 84, but it was that sort of super athlete. I got the MRI, didn't have fatty infiltration. They were very strong on exam. So I think a histopathology would be ideal, but an MRI I think can be a reasonable surrogate for cuff tissue quality if you need to make that decision ahead of time. Thanks. I appreciate that. I'm just wondering where we are. Do we have the talk ready? Okay. It's all set, Kat. Perfect. Be sure to give time for the case panel discussion, but does anyone have any other questions or any questions for Troy? Kat, thank you. And I want to congratulate the panel for just an outstanding session, but I had a question for Dr. Dennis regarding the frozen shoulder. When they come to my office, they're all stiff. So one point that I learned in the gray hairs, many of these patients are pre-diabetic, not diabetic, they're pre-diabetic. You look at their serum insulin levels, a whole other discussion. But my question to you is like stage one, stage two, would it be safe to say for the audience that anyone who has pain would benefit from an injection? Because in my feeble mind, they're all stiff pretty much, but would that be a safe assumption that synovitis equals injection? I think that's a great point. And what I learned when I was doing my fellowship with Dr. Hannafin was she was very attentive to trying to pick up these stage one patients. And I think because she's studied extensively the pathophysiology of adhesive capsulitis, and you see from our results that if you do that injection, if you catch it, if you diagnose it early and you do that injection early, you can save the patient months of pain and physical therapy. So in her practice, she has every single patient, she examines them all standing, and she has every single patient lie down and she does a full range of motion exam supine because she feels that she can pick up these subtle pain at end range of motion, which she tends to feel like if they present with night pain, if they present with pain at rest, and they have this subtle discrepancy between sides, that they could probably benefit from an injection, whereas that might not be picked up if you just have the patient standing. That's good. And I have one last question for the panel and for Dr. Shields. So you know, your study was really interesting and obviously saving patients from undergoing surgery is great, but if you don't have a non-operative sports medicine clinician who can take the 20 or 30 minutes to do this, do any of you have any thoughts or advice on how you might incorporate this into your practice? Yeah. So actually we trained a PA on this in my current practice. So it is a time consuming procedure, but I think the benefits are pretty obvious and borne out in the literature, not just our paper. So we actually trained up a PA to get pretty good at it, and that x-ray I showed was actually her case where she was able to aspirate the entire volume. So it can be time consuming, it can cut into, you know, for us on the private side, our billing and you're only getting an aspiration code out of it. So putting someone like that in charge of it, I think has made a huge difference. All right. Well, thank you so much. Thanks to the panel. You guys all did an excellent job. Really appreciate it. Thank you. Is there a microphone? Oh, there we go. Most people say it'd be a good thing. Is Craig here, Colonel? He's what? Patoni? Have you seen him? I haven't seen Craig. Okay. We're gonna finish strong, and I'm gonna be, my wife is picking me up at a timely fashion, so if I'm late, I'm gonna pay for it. But I wanna thank Cassandra for an outstanding, absolutely outstanding program. I just, you know, and where's Rick? Is he around? Rick, is he hung over again? Okay, anyway, let's give it up for Cassandra. Thank you.

shoulder injuries

rotator cuff tears

subscapularis tears

mechanisms of injury in older patients

treatment options for older patients with rotator cuff disease