Good morning, good morning to all the brave souls that are here on Saturday to listen to special day It's been my honor. My name is Kurt Spindler I'm your president of AOSSM and it's an honor to be here to serve all the wonderful members and very talented in this organization Very pleased today to say that we have something special We have a talk by our society members the that we have partnered with over the last 20 years the OTA Ankle-foot Society POSNA ASCS and Anna and we're looking forward to those speakers Second thing is we have our 50th anniversary in the Broadmoor in the summer. We hope to see you there I expect the crowd to be much larger at that point But I thank everyone for being here And finally, I need to thank our program chairs Rick Wright and Cassandra Lee for a great program and I'll turn it over to them But thank you all for coming today All Right, good morning everyone and with that I'd like to introduce the first two moderators Jeff Behr and and Michelle Wolcott, please come on up All right, thank you My name is Jeff Baron from the University of Wisconsin. I get the privilege of introducing our first speaker. Dr Walt Lowe who is going to speak today on quadriceps tendon autograft exhibits similar outcomes At return to sport in two years when compared to patellar tendon autograft for primary ACL reconstruction Thanks Jeff and thanks everybody for coming this morning and thanks to the committee for Letting me give this talk. It's a great honor to be up here at this Meeting so I'll start and this is pretty simple pretty straightforward talk. So You know, here's my disclosures. They don't affect this at all You know, there's sort of been some conflicting evidence and those of us that do a lot of very high level athletes there's been a resistance to switch from The patellar tendon graft to the quad tendon graft. And so in my practice I find myself switching more and more and more on a daily basis without a good reason for doing it Which is why I wanted to look at this So so the reason for this study was to compare re-injury rates I can read better without these to the re-injury rates and functional outcomes and return to sport rates at two years in a very athletic population undergoing quad tendon and patellar tendon Autograph is their primary ACL reconstruction of the inclusion criteria. You can see it's a retrospective match case control study This is sort of our study design the strobe diagram So so the return-to-play outcomes that we looked at to compare these two there had to be at least a 90% Symmetry between the well leg and the operated leg and all of these knee range of motion double leg counter jump single leg hop test pro agility drills the single leg balance and then the isokinetic testing at both At all three speeds you see and then the two scores. So Self self-reported function at two years We looked at SANE score and the Kujala anterior knee pain score and then injury surveillance We looked at graph re-injury and we surveyed them every six months out till they were past the two-year period So when we get into it the baseline demographics were the same So anything you wanted to look at including the mark score very evenly matched group When you look at function return to sport really everything but the single leg balance It was not a statistically different between the two populations and when you look at that with the criteria for sort of passing return-to-play both were well above the 90% tile for passing them in return-to-play, but there was a slight advantage on that side to the quad Tendon graph when you look at to your outcome same thing nothing Really that is statistically different between the two other than return to level one or level two sport where there was a statistically significant difference between patellar tendon and quad tendon and that leaned more towards towards the Towards the the patellar tendon side of this Everything else no difference between the two So in this Group there was no difference in graft re-injury self-reported function objective functional performance severity of anterior knee pain and you know, so I Really think we can just say pretty Pretty confidently that there the graphs are equal and return to very high level athletic activities And then just to acknowledge the PT group that that I work with that Got us all this data. So thank you very much for letting me present this All right, and then we'll now introduce our next paper a modified Lemaire approach of her lateral extra articular tenodesis in high-risk adolescents undergrowing anterior cruciate ligament reconstruction two-year clinical outcomes Presented this morning by Frank Cardasco Thanks, Michelle, it's great to be here Dr. Daniel green and I we were sort of research partners and the rest of our Crew as you can see are really thankful to the program committee for being here These are my disclosures which are available on the Academy website I think we're all well aware that revision rates and young athletes are higher than older cohorts this systematic review and meta-analysis out of Cincinnati from colleagues Demonstrated that the second ACL re-injury rate under the age of 25 was 21% and importantly if you were under 25 and had an ACL Reconstruction you were 30 to 40 times at greater risk of an ACL injury compared to uninjured adolescents The impetus for this current study is really based upon our previous experience in which we looked at 324 reconstructions under the age of 20 We divided the group into cohorts based upon skeletal age and while the youngest and oldest cohorts did pretty well as you can see We found this group to to be unacceptable with a 20% failure rate poor return to sport rates And they had all had a complete transphysiol hamstring reconstruction as a result of this study We made two changes we transitioned from a hamstring autograph to an all soft tissue Quadriceps autographed in that population of athletes and we added an let in a subgroup within the cohort based upon several factors Recent literature has demonstrated that lateral extra articular reconstruction reduces failure rates of hamstring autographed reconstructions Two landmark papers are listed here Sonari Cote and his colleagues in Lyon using an ALL reconstruction combined with an ACL and Alan Getgood and Multiple authors involved in the stability to stability one study, excuse me demonstrated similar findings with an LET However, there's a paucity of outcomes data available for high-risk young athletes treated with quad or BTB Combined with an LET and our purpose was to evaluate the two-year clinical outcomes of ACL reconstruction with quad or BTB combined with an LET Using a modified lamar technique and athletes 19 years or younger. It was a consecutive series of combined reconstructions The indications for LET in our hands and related to number one demographics These are relative but these young athletes who were involved in high-risk sports as well as the eighth and ninth grade Population on the bubble between middle and high school seemed to be a particularly high risk So these were relative on physical exam recurve item 10 degrees or more bait and six or more grade three pivot anterior translation greater than seven Radiologically increased lateral tibial slope decreased notch width index and large marrow edema patterns involving the LTP in the LFC Surgical history was also relevant if they've been treated non-operatively and had a chronic ACL insufficiency with stretch secondary restraints We indicated them for an LET if there were contralateral or revision reconstructions as well similarly The post-op PT and rehab was standardized including the quality movement assessment and the return to sport program The outcomes measures we used or as listed We had two types of reconstructions for the truly skeletal immature with three to six years of growth remaining We used an all epiphyseal with a quad autographed for those with closing or closed growth plates We used a complete transphysiol reconstruction with quad or BTB Our previous we've published these techniques in terms of the quad harvest and the preparation And we've also published the modified Modified lamar technique in this population of skeletal immature athletes as well Study results we had 63 athletes enrolled We lost two to follow-up 61 were followed for 96.8 percent follow-up rate The mean follow-up was three just over three years of the range of two to five Females were the majority 37 out of 61 or 61 percent Mean age was 15.2 with a range of 11 to 19 and the median grade in this group was ninth grade Ninety seven percent were involved in travel club or school levels of competition The most common sport was soccer as you can see from the distribution in terms of procedures primary Reconstruction were performed in the vast majority 51 of the 61 or 87 percent Complete transphysiol were also the vast majority 54 out of 61 or 89 percent Quad was also the primary graft in this population 60, excuse me 42 of the 61 or 69 percent all had a modified lamar and implant mediated guided growth was used in two patients with valgus alignment 10 athletes or 18 percent had ipsilateral Procedures only one was a revision that was in the BTB group for one person point seven percent revision rate Meniscus surgery for those incompletely healed repairs or new tears with an intact graft and stable knee were required in seven Lysis of adhesions and removal of hardware in two each and unfortunately eight athletes 13 percent had contralateral ACL reconstructions The outcomes of measures were respectable as you can see the return to sport rate was 87 percent so in conclusion Combined let modified lamar with quad or BTB autographed and high-risk pediatric and adolescent athletes with non modifiable risk factors Results in satisfactory outcomes high return to sport and low ACL rupture rate at minimum two-year follow-up The significance we believe this is one of the first studies to demonstrate that let can be performed safely in combination with ACL Reconstruction to improve outcomes in high-risk pediatric and adolescent athletes. Thank you for your attention Thank You Frank, okay, so our next speaker is Dr. Eric Bowman he's gonna talk about restriction blood flow therapy how and when to add it to PT protocols Frank trying to I'll try to get this thing Get back to you in a second Thank you for the opportunity to speak this morning quick poll of the audience here who is familiar with blood flow restriction training or fairly Familiar with it So most people and who uses it on a fairly regular basis Okay, who really hasn't heard much about it at all I'd say three or four years ago. Those numbers were probably flipped who is still pretty skeptical about it Okay, so most of us have a decent understanding So let me kind of go through how I use it in my my practice here a Little bit about what it is We having a little issue it's not opening up I So we'll just go a little bit out of order and have I'll get good present his technique video on the lateral extra articular tenodesis Predicted that Okay, so thanks very much for the invitation to give us talk and really just focusing on the technique for let So I'm I'll get good from University of Western Ontario Fowler Kennedy Sport Medicine Clinic And we'll talk through the technique for lateral tenodesis. These are my disclosures And they can also be found on the Academy app So I think first of all when you think about a technique We've got to think about indications and certainly for me indication the first one be for revision ACL reconstruction and This is based on the fact that there's a number of studies now that have shown Improved rotatory stability as well as reduced failure rates in the revision population And if I look at my data as long as well as Volcker Mussel's data from University of Pittsburgh We've shown that over the last 10 years our utilization of let and the revision scenario has certainly gone up gone up over that 10 year period in terms of primary ACL reconstruction I'm using it in young patients who one thing a hamstring tendon graft and then patients who Exhibit a high risk Factors that may put them at high risk of re-injury so that's young patients under the age of 25 patients with generalized ligamentous laxity particularly knee extension Recurvatum and then going back to pivoting sports as well as patients with tibial slopes greater than 10 degrees and Then a chronic lateral notch greater than 5 millimeters so what's that based on what's based on our predictors of outcome and from the stability one trial and this was a multivariable logistic regression where we tried to look at what what would indicate us to be able to for this patient population and Certainly, we showed that the use of an let reduced our odds of graft rupture by 60% And it's important to note that this is in a hamstring tendon population And then age so a older age certainly is more protective we look at return to sport so if you are If we delay return to sport our graft rupture rates are reduced High grade knee laxity preoperatively so again This is something you can work out in the office as well as in the OR and examination under anesthetic Just over three times higher odds of graft rupture and then posterior tibial slope And what we did is we've plotted age against tibial slope And we see that the risk really starts to increase significantly around about the 10 degree mark so again These would be indications for the use of an let Question I get asked a lot is what if I use a patella tendon graft? we've looked at our data along with the the moon risk calculator and I show that pretty much that the hamstring tendon plus let is a fairly similar to a patella tendon graft Not being said there may even be some Some offer the let may offer an additional protection particularly in these high-risk individuals And that's the subject of our stability to trial and we'll hopefully share with you in about five years time when we finish it So what is the the technique well? This is a lateral skin incision just based slightly posterior to the lateral epicondyle It's a small incision. That's not like the old Macintosh procedures about five centimeter incision. It's very straightforward very simple So the incision is based Which would be basically find the IT band We find the posterior aspect of the IT band and then go about a centimeter anterior to that I take a strip of of the posterior half, so it's one centimeter wide and approximately eight centimeters long It's a general rule of thumb when you reach the vastus medius vastus lateralis Muscle belly you probably have enough tissue in terms of its length You do not need to extend it all the way down to Gertie's tubercle It just needs to be mobile enough so that you can get it underneath the fibular collateral ligament So again pretty straightforward the graft is there for you very easily to use It's amputated proximally and then a whip stitch that with I tend to just use a one vicaral Whip stitch and then once we once we put the whip stitch in I'm going to find the fibular collateral ligament To do that you can either drop the leg underneath the table depending on your setup and just push the leg into verus So or put it into a figure four position that's easy to find the FCL and then we make two capsular incisions one anterior one posterior and Then I use a metzenbaum scissor and just pass it from anterior to posterior Underneath the FCL once we've done that I'll pass some form of artery clip And that essentially allows us to shuttle the graft from anterior to posterior Now you can see there's a little bit of bleeding there You can do this really either with the tourniquet on or or off the important thing is that you must release the tourniquet at the End of the procedure. There's a leash of vessels there the lateral geniculate We need to make sure that you've got hemostasis at the end of the procedure because the risk of hematoma hematoma formation post-operatively In terms of the insertion point we just take some of this fascial tissue off getting down onto the metaphyseal flare and then fixate this with a Richard staple, so it's a small staple Minimal tension being applied to the grafts less than 20 Newtons with the leg held neutral rotation and at about 60 degrees of flexion and then the graft is sutured back onto itself and Finally again hemostasis control to release the tourniquet if you use the tourniquet and then close the ITB proximally, but don't you do not need to close it all the way down to girdies for fear of Over-constraining of the telepharmal joint a couple of very simple points in terms of the fixation point as a study from Andrew Amos and Andy Williams So the McIntosh point and the Lemaire point is as long as you're basically along the posterior cortex of the of the distal femur Then we shouldn't have any issues the graft passed under the fibular collateral ligament to allow for satisfactory isometry the fixation device Staples and inexpensive easy to use and solid You can of course use suture anchors a little bit more expensive may not give you quite as good fixation Interference screws are also good a little bit more expensive. But again, there's a higher risk of tunnel coalition There's also a risk of cutting the graft. So all of these are satisfactory options. You just could be aware of the pros and cons Thanks very much for the invitation and for listening. Thank you All right, thanks now for being flexible so we're now we're gonna have dr. Bowman come back and talk about blood flow restriction therapy All right full start Okay, so what is blood flow restriction therapy well blood flow restriction therapy is Exercise performed under low load Environment, but you're still getting the same physiologic effects as a high load stress Basically, if you've been to the gym and you see a weightlifter working out with a band across their arm They are taking advantage of this physiologic process. What we want to know is is it safe for our orthopedic patients? So dr. Sato Actually over 60 years ago almost six years ago Started playing with this He noticed when he was praying in a traditional Buddhist pose that his legs got the same vascular congestion as when he worked out Well, he took this to the extreme He had complete occlusion for long periods of time actually gave himself a DVT and a PE and some nerve damage But that didn't stop him. He kept going and refining these techniques and now we have a much safer Option But it has been in the strength conditioning World for quite a long time and has just recently become more in vogue And what we want to know again is is it safe to use for athletes? But of course, it's gonna be ideal for tissues that are Underload that we don't want to load or because of injury or repair. So how does it work? Well, essentially you're creating a localized hypoxic environment So an anaerobic state that is then going to increase protein synthesis decrease proteolysis increase your stem cell viability and ultimately lead to muscle hypertrophy and strength so there are a variety of Applications out there they range in price from $10 to 6,000 active pressure monitor management is where the machine actually Modulates the pressure as you go through the range of motion and that's probably a safer option than just strapping something to your arm and telling Somebody to go work out So who's using it? Well pretty much all of our professional teams and collegiate teams have this in their athletic training Arm inventarium and use it on a fairly regular basis And this is really where the sports performance world has outpaced what we've been Able to research and look at in the orthopedic world. So what does the standard protocol look like? Well for There really are no set protocols and at least based on evidence And so I'm interested to see what one of the studies later today showed as far as their protocol But in general you start with about 20% of the one wet one rep max weight or you can even start with body weight And Vascular occlusion we don't need to get to 100% really all you need is 50 to 80 and some of the studies have shown that really on the lower side is is just as effective So there are various protocols out there typical ones, you know, four sets 30 second rest between multiple exercises performed in series and You increase the weight so that you maintain a perceived exertion of about seven to eight There's another thing out there that you'll hear about ischemic preconditioning really there's no evidence and yet in our orthopedic literature But it's where an athlete will completely occlude for about five minutes just sitting there and then they'll go work out So what are the clinical indications? Where should we think about using this? Well, one of my colleagues is actually Looking at femur fractures and Department of Defense Grant and the Department of Defense is very interested in this technology and it's funded a lot of these studies So maybe a potential for bone healing you'll see that the orange is where there's maybe insufficient data or mixed data to make a conclusion Near arthroscopy some of the early studies have shown that there is an increase in strength and there's probably more evidence towards decreasing effusion in pain But still mixed at this point now ACLs where it becomes interesting because we all want to get our athletes back as as quick as possible Probably one of the better done studies was this one that did not show an effect But they didn't start therapy until this therapy until about 10 weeks out only did one exercise and they started with high load Exercise and so that's not really the population that or that's not really the protocol that most people follow Be more typical of the second where you start it maybe a couple weeks post-op out low load That's really where you're gonna take advantage of this therapy the most so also in Athletes over 50 even just walk training Proximal effects and systemic effects are interesting to think about some of the early rotator cuff studies haven't shown a difference but there is a well-known systemic or crossover effect in throughout the sports training world and To some degree BFR probably capitalizes on this a little bit And there are certainly many studies currently Underway, so the biggest problem is probably bias. These are generally small studies and you can see there that red This is a Cochran bias summary list and basically Blinding is a little bit difficult to do on these studies and so they are at risk for bias Who should not use BFR? That's probably the more important question. So anyone who's at risk for venous thromboembolism If they have if they cannot tolerate increased workout cardiac output If they have any type of peripheral arterial or vascular disease But in general what we've seen is that in across the across the board really in healthy individuals risk has not been increased in Healthy individuals. We haven't seen an increase in markers of clot formation or thrombin production Rabdo is certainly a concern and there have been several case series which have been somewhat confounded but These are the patients who need to be careful in so questions still remain. What is the ideal protocol and various indications? When do we start this therapy? when do you feel comfortable letting your your patient do this, especially given the potential for hypercoagulability and Really? This is probably the biggest thing. So neuromuscular adaptations have to accompany the hypertrophy think of blood flow restriction like a Cheat code it gets you to the to the point where you're training that muscle and an effective way sooner But at some point you got to play the game. You got to get that neuromuscular control in there to actually Capitalize on it. So when do we transition from low intensity to the more standard height intensity routines? And of course continuing to make sure it's safe So in summary BFR is useful adjunct to standard PT as it induces the same physiologic effect as a high load training Environment under low load stress. We are still defining our clinical indications, but think about those patients that can't tolerate a high stress load and We still don't know the outcomes as far as healing rates time to return to sport, etc So we still need more high quality data, but in general seems to be safe for the majority of our healthy athletes Caution in those risk for clots and nerve or vascular injury or compromise or cannot tolerate increased cardiac output Thank you All Right, we have time for some questions now Nice talks, thank you so much. I have a question for Frank Cardasco I do too like the quadriceps tendon a lot and you know Freddie Fu obvious taught the over-the-top position quite a bit especially in pediatric Have you found a way how to use the quad in that situation? If not, what what would be your preferred graft for the true? Fisius bearing Just to be clear Volker. I want to make sure I understand the question. So you're thinking in the very young child Seventh sixth grade where the Fisius is very close posteriorly Yes But also in a revision setting over the revision setting it and I know Freddie liked to go over the top with revisions I hear that from his former fellows. I've used it occasionally if I want to avoid a Second stage in terms of bone loss So if you really felt that the distal femur was compromised from the standpoint of bone loss, I will go over the top I haven't used the quad to go over the top. Obviously the maximum length we can get is generally about 70 70 millimeters Excuse me, so I haven't used the quad in that setting No, I've never gone over the top ever I Have So what we'll try to speak over it question for you and Frank to And now you may want to weigh in when counseling a patient now that we're seeing very good results with quad and patellar tendon Classically, we've been using patellar tendon a lot of our high-risk athletes, but now I'm using quite a lot more as well I'm just curious about your Discussion that you have with a patient about which graph to use and then your discussion about adding le T onto those I think those are both great questions And you know this gets back to stability to which I think we're all looking forward to seeing so it's really how you Present the discussion. So in our case, it's often with parents with with the child with the adolescent and even if they're 17 or 18 we see generally we'll see them with their parents So the for me the answer for quad versus BTV is I'm very frank with them and that is I think they're equal You could make an argument. There have been some system systematic reviews looking at graph I'm sorry donor site morbidity and in some cases those those Systematic reviews come down on the side of the quad because you have less Potential for in for patella branch of the saphenous nerve associated numbness and donor site morbidity Obviously fracture while rare is always a possibility if the individual lands on a hyperflex knee in the early post-op period That's a tenant generally obviated with quad but in terms of outcomes, I think they're equal So so I'm honest with them I talked to them about the historic advantages of BTV just because of our outcomes that we don't have the final data on quad but if we we've been doing it now at HSS for several years and Dan Green presented our quad data earlier in the week at the Academy and the results are very favorable So I sort of leave it up to them I discuss all of that and those conversations can be about 30 or 45 minutes as far as the LAT goes I usually say that in this situation we've identified these factors to be at high risk in young adolescents for recurrence and If you frame it that it's an insurance policy to keep your adolescent out of the operating room a second time and lose another year of high school or collegiate sports It usually resonates with the family, but these are difficult discussions and you really need to spend time with the family Just a couple things to add to that because I agree with all that first. I think there's a reason now to know the parameters of your patellar tendon grafts of measuring with Measuring length those kind of things can be one of the things that pushes me away Especially in the young female soccer player with the tiny, you know, patellar tendon with the tibial insertion of 12 millimeters or something like that. I've sort of used that argument to move away from the patellar tendon in that group. When all those things are equal and I go through the whole graft discussion and everything you get there, I end up sort of phrasing it like you, I say between quad tendon and patellar tendon, I think it's a flip of a coin and then it has to be trying to know your patient, know how aggressive they are and I still lean towards the patellar tendon in those young people that I know aren't going to listen to anything I say, I'm going to go push as hard as they can because honestly I think it slows them down a little more. You know the slope question is one that, you know, you're at 10, where are you when you add the LAT? Yeah, we published a paper several years ago, David Dare was the lead author, it was AJSM, looking at about 150 pediatric and adolescent injured athletes. Half of them were ACL injured and the other half were other factors, OCDs, et cetera. We measured slope and the ACL injured athletes were at greater risk based upon a 5 millimeter difference, I'm sorry, a 5 degree difference. So I agree with what Alan presented, he uses 10, we sort of say 7, 7 to 12 to 13, I don't think any of us are doing slope correcting osteotomies on a primary case, but certainly in the revision setting if you're in the teens, one begins to think about that. I think it's, I'm not sure we have the final result or the final answer as far as slope goes, but I agree. The only additional comment I'll make related to BTB versus quad, if you have a 110 millimeter BTB, in that setting I'm moving more towards quad, obviously you can recess the graft on the femoral side if you're using suspensory fixation, but I just worry about that thinner 3 to 4 millimeter tendon on the femoral aperture. And obviously Osgood-Schlatter is if it's really significant. Rick, you have a question you'd like? Contraindication for oral contraceptives, could you give a little more detail about how you manage that in people on contraceptives? Sure, and I'd say relative because I think if you do it in a safe way and it's monitored and under observation with a therapist, you're going to be in a safe environment. Most of my patients I put on a baby aspirin anyway, and if they may be a little high risk, so oral contraceptive plus, maybe they're a smoker or elevated BMI, be more cautious in that type of patient, and so I kind of risk stratify if it's just an oral contraceptive, but I'm less concerned if it's an oral contraceptive plus another risk factor, then I'm going to be more likely to avoid it. Just one final question about the BFR. So when you're discussing that and using protocols, do you individualize the protocols for the athlete or the type of athlete, maybe the sport, et cetera, thinking of, say, a gymnast versus a swimmer, something like that? Yeah, I think that's a great question, and a lot of this is run by the physical therapist, and so you see studies where they, some studies they just do a single leg press, or they'll, I like to start it even when they can start doing straight leg raises or abduction, hip extension, so really even with minimal motion of the knee, so for me, it's early enough in the process for most of my athletes where they're going to be doing the same quad sets and those type of exercises. As you get further in, you could certainly question about whether you're getting into more sport-specific strengthening, and we just don't have the answers for that yet. Okay, one final question. Okay. L.E.T. One of my international fellows came to me the other day and said, you know you place your staples all over the place, and I said, no, I'm not. He then proceeded to show me a plot with all the staples that I placed everywhere. So Al, have you found any differences in outcome based on whether your staple or, you know, fixation point is truly at that Lemare or McIntosh spot or somewhere, you know, different? The easy answer to that, Volker, is no, because we haven't looked specifically at it. You think it matters? But we probably should. Now that being said, you know, the fact that we do have maybe a variable position from time to time, it's actually, that's one of the benefits of doing the procedure because we go underneath the fibroclateral ligament. So actually it's much, much more forgiving in terms of your insertion point. And so, you know, you're really getting the tenodesis effect from the fulcrum of the FCL insertion. If you don't go underneath the fibroclateral ligament, it's been shown in studies from Andrew Amos' lab, if you don't go underneath the fibroclateral ligament, then you have to be much, much more precise with your fixation point. So if you're starting out doing an LET, go under the FCL, much, much more forgiving, use whatever fixation device is comfortable for you to use. Thanks. One last comment, Walt and I had mentioned that we failed to discuss really full thickness quad versus partial thickness quad, and we both feel full thickness is the better graft, but there has been some discussion in the literature. Yeah, just all of those in my group are full thickness, and I really think, and we're looking at now, there's significant strength in that capsular layer there, and so all of those grafts were full thickness quad tendon grafts. Do any of you use bone at all? No. I do. It increases that length, right? So I mean, that's part of what we'll be looking at in stability too, because across all of our sites, we have a variation in terms of the surgeon use, so whether it's full thickness, partial thickness, bone, no bone, and, you know, the studies, the randomization stratified by surgeons, so hopefully we can, with subgroup analyses, be able to try and get a little bit of a better answer to that. My argument for using bone is that, well, why would you not use it? It's one of the major, you know, I think it's one of the benefits of using an extensor mechanism graft, because you get early fixation. So, but we'll find out. And you get length, right? You get more length, yeah. And just one follow-up comment. In the pediatric and young adolescent group, we avoid the bone, obviously, but we found the soft tissue graft to be effective, and we should point out that the Pittsburgh group, Volcker and Dr. Fu, demonstrated a higher fracture rate based upon the changes in the morphology of the patella, so you should be aware of that as well, and obviously you are. And that was a very elegant demonstration of the LET. One final comment on fixation. I think we all agree that it shouldn't be over-constrained, and so the question really, and when I first saw David DuJour do this several years ago, he used an interference screw. We probably could use minimal fixation there. So Walt and I both use all suture anchors, and really just fix it just proximal and posterior to the LCL insertion on the femur, and it's worked well in our hands. I think by doing that as well, you decrease your risk of tunnel convergence, or putting a staple into your femoral tunnel, because even on your picture, Frank, you had that area, you were really close, you could see the sutures coming out in the same area. So I just want to address Volcker's question. I got real tired of seeing mine all over the place, too, because I didn't think they were. And so I actually went to using the Mini-C arm. It takes me about two minutes, and now I feel like I'm perfect every time. And I was really surprised how they were sprayed all over the place, you know. Good morning. We're going to go ahead and start with the shoulder session. I'm Ashish Bedi from the University of Michigan. My co-moderator is Carolyn Hetrick from Brigham and Women's. And we're going to start with our first paper for this session, which is from Tawfiq Jilday at Henry Ford Health System. It's a multimodal pain regimen. It's equivalent to opioid analgesia following arthroscopic shoulder surgery, a prospective randomized trial. And the presenter will be Dr. Okoroha. Tawfiq. Thanks, Ashish. Tawfiq had a family emergency, so I'm going to be presenting this for him. Neither I nor my co-authors have anything to disclose. So with the declaration of pain as the fifth vital sign, there's been increased focus on treating acute and chronic pain throughout the 1990s and 2000s. In fact, opioid prescriptions have increased from 76 million in 1990 to 224 million in 2012, which has led to a six-fold increase in the death rate. Studies have shown that in patients that are presenting for a treatment of narcotic addiction, they quote the primary reason for their primary exposure to opioids was postoperative analgesia. And now today, America finds ourselves in an opioid epidemic. Postoperative pain management continues to be a challenge for orthopedic surgeons. Studies have shown that orthopedic surgeons are a large percentage of overall opioid prescriptions in the country, and therefore are uniquely positioned to curtail the opioid epidemic. So the purpose of our study was to perform a randomized controlled trial comparing a multimodal non-opioid pain protocol to traditional opioid medication, and to determine whether postoperative pain control in patients undergoing arthroscopic shoulder surgery. This was a prospective randomized single-blinded trial from August 2019 to December 2020, in both rotator cuff repairs and labral repairs, and these were two separate studies. We randomized the patients into two treatment arms, one treatment arm for orthopedic surgery and one treatment arm for postoperative pain control. We randomized the patients into two treatment arms, one traditional opioid analgesia, and then one novel non-narcotic protocol. We initially evaluated this in a cohort series in ACL surgeries, meniscus surgeries, labral surgeries, and rotator cuff surgeries, and we found that it was ineffective, and patients only used one to two narcotics, and then we then sequentially performed four randomized controlled trials. Study breakdowns, 70 patients in the rotator cuff group, and 60 assessed in a labral group. So what are the protocol we used for both groups? They got a preoperative nerve block, intrascalene block, and then preoperatively they got psilocopsic acetaminophen, gabapentin, and tramadol, and intraoperatively they got dexamethasone and toradol. Before closure, they also got local infiltration anesthesia. Postoperative for the opioid group, they got five milligrams of hydrocodone and 325 milligrams of acetaminophen, and we told them to take one to two pills orally every four to six hours. For the non-opioid group, we gave them Ketorolac, gabapentin, Robaxin, and Tylenol, and they were told to take this three times a day with additional optional dose before bedtime. For outcomes, we used PROMIS scores. Those were taken preoperatively and at the first post-operative visit, and then we used the MOZIO system to obtain VAS scores three times a day. We also collected side effects and complications. So what did we find? There was no demographic differences in terms of age, sex, BMI, or race between the two groups. There was also no difference in surgical factors when looking at procedures performed or pathology. When accounting for age, sex, and gender using an estimated equation model, we found that the patients that used the non-opioid protocol had significantly less pain throughout the study period. There was no significant PROMIS pain interference scores preoperatively. However, in the labrum study, the non-opioid group had lower pain interference scores. This was also demonstrated in the pain equation model. When looking at opioid consumption, we found that most of the patients in the opioid group used most opioids in the first two days, whereas that curtailed throughout the study. And there was no significant days reported without side effects. However, the most common side effect was constipation, and this was found significantly to be increased in the traditional group in the rotator cuff study. We found no intraoperative or post-operative complications in terms of DVT, surgical side infections, and 100% of patients in the non-opioid protocol stated that they were satisfied with their pain management. There was also no reported complications with the non-opioid group, and no patients required emergency opioid analgesia. So in conclusion, in patients undergoing arthroscopic shoulder surgery, rotator cuff, or labor repair, the multimodal non-opioid pain protocol demonstrated least equivalent pain control compared to the opioid group. The side effects were minimal, and patients were 100% satisfied with their pain management. We evaluated that now in four randomized controlled trials that were published last year that demonstrated that this protocol is efficient. We want to note that surgeons can feel free to modify this as they feel necessary with different medications, and that we find that this should probably be extrapolated to other surgeries as well. Thank you, everyone, for your time and attention. Next, we'll hear from Dr. George Murrell from the University of New South Wales looking at the effects of glenohumeral osteoarthritis on early clinical outcomes following arthroscopic rotator cuff repair. Thank you. Thank you. This is work done by one of my students in lockdown in Singapore. As we know, rotator cuff tears are very common and cause lots of problems and are often repaired. One thing we often see during arthroscopy, though, is arthritis or mild arthritis in the joint, and we had the question as to whether this was a benefit to the repair or detriment to the repair. We've done some studies that show if the shoulder is stiff enough to require an arthroscopic capsule release at the time of surgery, then the re-tear rates are very low, in fact, zero. We've also shown that if you get stiffness at post-op, six weeks, there's a much lower re-tear rate than those that don't get stiffness at six weeks. And we've shown that this effect persists out to eight years. So there's certainly some data that suggests that a stiffer shoulder from arthritis might be protective. On the other hand, arthritis is associated with age and this is associated with a lot of degenerative conditions, and we know that the rate of re-tear post-rotator cuff repair increases quite dramatically as we all get older. So it's quite likely that arthritis might have a negative effect on healing post-rotator cuff repair. So the aim of this study was to find which was the case. To be included, you need to have a primary rotator cuff repair done during this time period and have an assessment during arthroscopy for arthritis and have an ultrasound of six months. We excluded things that might confound the outcome. So after exclusions, we had a little over 2,000 patients. Of those, about 60% had no arthritis in the joint. 27% had grade 1 arthritis, 14% grade 2 and 2% grade 3. The arthritic group, as you expected, were about seven years older. Interestingly, the left shoulder was more commonly affected and there were more arthritic shoulders done as I did more cases. In terms of the intraoperative findings, the arthritic shoulders had slightly larger rotator cuff tears compared with the control group, about two millimetres in each direction. Also, they had poorer rank tissue quality, repair mobility and repair quality. So pre-op lift, as you'd expect, the arthritic group on average had a loss of nine degrees range of motion in all directions. Post-operatively, they all improved but on average, they were still seven degrees stiffer than the non-arthritic group. Similar changes in terms of strength. On average, the arthritic group were four degrees less strong, four newtons less strong in terms of the strength tests and while they all improved, they were still four newtons less strong than the non-arthritic group. In terms of all our outcome measures, really the outcomes were pretty very similar in terms of the two groups. Our main outcome measure, rotator cuff tear integrity at six months, the arthritic group had a re-tear rate of 15% compared with 11% with our control group. But when we did a multiple regression analysis, this was not a factor. The factors that were important in determining whether or not the arthritic group was a factor. The factors that were important in determining a successful outcome were tear size, smaller tears were more likely to heal at six months if the surgery was done in a private institution with greater experience of the surgical team and in a young person and if the surgery was done fast. You can see the Walter statistic F shows the effect size of each of those characteristics. So the study weaknesses, this was a single centre, single repair technique. We didn't differentiate between primary and secondary osteoarthritis in a relatively short follow-up period. The strengths were a large sample size and good internal validity. So we did find that osteoarthritis was not an independent predictor of re-tear at six months. There was a slightly higher re-tear rate but this was due to other confounding factors. Patients who had arthritis had slightly less range of motion and strength both entering and exiting the surgery and very similar pain and shoulder function scores. So to answer our question osteoarthritis at the time of surgery really doesn't affect whether you're going to get a successful repair or not. Thank you. Thanks George. Our next presentation will be on glenoid labral tears and associated increased neurofilament innervation from Dr. Jeff Murphy also from the University of New South Wales. Thank you for the opportunity to present this paper. We have no relevant disclosures. Pain is a common presenting feature of symptomatic labral tears particularly slap tears. However, the cause of the pain is undetermined. Three cadaveric studies have found free nerve endings throughout the glenoid labrum. However, none of these studies measured the concentration of nerve fibres nor evaluated the concentration of nerves in the labour of patients with symptomatic labral tears. Consequently, our study aimed to determine if nerves are evenly distributed throughout the glenoid labrum. Our second aim was to determine if the distribution and concentration of nerve fibres changes after labral injury. We hypothesised that the superior labrum would have a higher concentration of neurofilament expressed in cells based on prior literature which has found that it has a differing tissue histology and blood supply. We also hypothesised that the concentration of nerves would increase at the site of a labral tear. For our first aim total shoulder arthroplasty samples were used to map the concentration of neurofilament expressed in cells between regions of the glenoid labrum. Samples were collected at 3, 5, 9 and 12 o'clock on a superimposed clock face. For our second aim labral tissue was collected at 3, 5 and 12 o'clock during shoulder arthroscopy from patients undergoing rotated cuff repair, anterior labral repair, type 2 slap repair and capture or release. The labour from patients with rotated cuff tears were sampled to represent an uninjured labral control group and those with adhesive capsulitis to represent a positive control group. These were then compared to patients with labral lesions. After sampling tissue was fixed in formulin and cut and placed onto slides. Sections were then immunostained with antibodies to neurofilament a major cytoskeleton element in neuronal axons and dendrites. The slides were then examined under light microscopy to determine the number of positively stained cells counted by a pathologist who was blinded to the patient's surgery. 39 patients participated in the study 7 in the first aim and 32 in the second aim. For the first aim we found that in untorn labrum there was a concentration of 8 neurofilament expressing cells per millimetre squared. There was no difference between the anterior, posterior, superior or inferior labrum. For our second aim at 12 o'clock we found that patients with slap tears or adhesive capsulitis had on average more neurofilament expressing cells than patients with rotated cuff tears though this did not reach statistical significance. At 3 o'clock the labrum of patients with adhesive capsulitis had significantly more neurofilament expressing cells than the labrum of patients with rotated cuff tears. The labrum of patients with anterior labral tears had significantly more neurofilament expressing cells per field than the labrum of patients with rotated cuff tears at 5 o'clock. There are no other differences between the groups. A strength of this study is its use of non-cadaveric tissue with all previous studies using cadaveric material. Neurofilament is also a well-established neuronal marker and has previously been used to examine the nerves of the glenoid labrum. Including the lack of a group with no shoulder pathology. There was also differing demographics between the groups and there was also small sample numbers particularly in the type 2 slap repair group consisting of only four patients. So, in summary this study showed that in untorn labrum there is little variation of neurofilament expression between the superior, anterior, posterior and inferior glenoid labrum. Torn labrum exhibited less neuronal expression particularly at the site of the tear. This study supports the hypothesis that following a tear of the anterior or superior labrum the labrum in that region becomes populated with new nerve fibers. These fibers may be responsible for many of the symptoms particularly pain noted by patients with slap and or Bankart tears. Thank you. Lastly, for this session we have Dr. Peter Chalmers from the University of Utah presenting on the effect of anterior glenoid cartilage defects on anterior glenohumeral instability a biomechanical study. In a prior study we demonstrated that these cartilage defects are oriented directly on anterior glenoid at three domino using the core face model. Mean defect size was 15 mm in length and only 8 mm in width. Normally the concavity in cartilage deepens the membrane socket also thus cartilage loss may contribute to recurrent dislocation. Even with dislocations contour defect could contribute to abnormal translation of the humerus relative to the glenoid. Purpose of this study is to determine the effect of incremental cartilage defect size on the anterior shoulder stability. Three years were tested. Mean age was 63 years old. All soft tissue was removed from the scapula and humerus except for the glenoid labrum and articular cartilage. Shoulder position was 60 degree abduction and neutral rotation relative to the humeroid head. The peak translation force was quantified and the stability ratio was defined as the peak translation force divided by 50 Newton compression force. Displacement direction was tested sequentially with the intact state and the defect of 3, 6, and 9 millimeter width in the anterior direction. There was a decrease in stability ratio between the intact state and the 3, 6, and 9 millimeter defects in the anterior superior direction. There was a decrease in stability ratio between the intact state and 3, and 9 millimeter defects. The present study of 3, 6, and 9 millimeter defects was thought to be critical. It has been reported that the defect of 25% significantly reduced the stability in abduction and external rotation. This result was almost the same as our study. Thus, to restore the stability in addition to repair, it may be necessary to reconstruct the defect even as small as 3 millimeters. The prior suggestion to promote biological healing during shoulder instability surgery may actually promote instability recurrence. In conclusion, anterior defect of 3 millimeter or more, 10% of granoid width or more increase anterior and inferior stability and recovery rate. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attention. Thank you for your attentI think a lot of us are concerned, but your paper as well, several other presentations, NSAIDs are coming back in, and not just Celebrex, but even I've seen Naprocin in one of the other papers, but I don't think we know really the effects of that, because 15 years ago we were all told to stop doing that. Right, right. Yeah, our thoughts are acutely, it shouldn't have a significant change, but it again has to be evaluated long term. While we're maybe waiting for other questions, I had a question for Dr. Murphy. You know, a nice study showing the potential ideology of pain with these labral tears absent arthritis. I guess a question in terms of the implications of your study findings for treatment. You know, so if you see this area of new innervation in the area of focal labral tears, do you recommend that that is denervated at the time of a labral repair, or do you think that that may have in fact some potentially additional value beyond being a pain generator, and we shouldn't necessarily change our treatment plan there? I think that probably needs to be evaluated further. As we've had a look at, the sample sizes are quite small, so we had a look at patient pain outcomes with that, and found that higher nerve concentrations were associated with higher pre-operative pain, but probably evaluating also for the higher nerve concentrations pre-op were associated with more pain post-operatively, would then probably help determine how much this needs to come into surgical planning. I have one more question for the first paper. Did you change your multimodal pain regimen depending on the size of the surgery? So for, you know, many rotator cuff repairs are much more larger surgeries than the labral repairs, and if so, how did you do that? Great question. No, we didn't change it based on, you know, surgical factors, and we found that those didn't have a major difference in terms of additional procedures performed or pathology. We did change it based on the patient's opioid, if they're opioid naive or not, because we found that patients that have had chronic opioids in the past need opioids post-operatively, so those are the patients that are not indicated for this. Great. Maybe a question I had for George. You know, wonderful study. Did you notice any differences in the implication of the tear pattern or the rotator cuff tear, if it was more of an anterosuperior tear or posterior superior tear as part one, and then the second is conventionally with arthritis, the incidence of tears was smaller, and you noted a small, larger size tear in the arthritic population. Was that significant, or you think more a small treatment effect? So the second question was, was there a larger tear size in... You noted a larger tear size in the arthritic group. Significance to that versus what's conventionally thought of less tears in that population. Yeah, I agree. It wasn't a big difference, but it was certainly a difference that patients with arthritis were more likely to have larger tears, and as the results show, the tear size is the more important factor in determining healing. In terms of tear configuration, that's not something that we looked at, no. It's purely size. I guess I'll conclude with one last question that I had, Kalechi, for your study. As part of your multimodal pain regimen, a regional block was a critical component, but you've done some prior work in the lower extremity as well. Are you able to parse out, as part of that multimodal approach, the relative importance of the regional block compared to the other interventions, or is there a treatment effect that's more important for one of those interventions than the others? Yeah, great point, Ashish. I think it's great to have patients have a preoperative block, especially procedures that can use it. I think that gives them at least a day of consistent pain relief, but I think even without using a block, and we found that with the lower extremity surgeries, that they're able to manage their pain with this non-opiate protocol without a block. Dr. Harner? Yeah, Chris Harner, Pittsburgh. So I have a question for Dr. Murphy. Your standard deviations were really big, but some seemed to be tighter. Was there a zone where you saw the superior, inferior, where the standard deviations were a little more consistent? Because I did notice that there were tighter standard deviations than there were really broad ones. Yeah, yeah. So it was quite interesting with that. It was actually in the labeled tear groups that there was quite a wide variety of neurofilament-expressing concentrations, with some patients having up to 32, but then others having just equivalent to the rotator cuff labrum. So it was quite a heterogeneous sample. It was the rotator cuff repair group that actually had very, really quite consistent. The highest we ever found in any field was kind of 10 neurofilament-expressing cells. So that was much closer, yeah. Interesting. Yeah. And just a question. Maybe I missed it, but what's the next step? What do you plan on doing next? I've not even missed your conclusions on that, but just curious. So I guess probably the next step would then be to look at if it's also associated with post-operative pain, and then also potentially looking to see if other tissue histology changes with labeled tears, particularly like blood vessels, inflammatory cells, things like that. Thank you. If there aren't any other questions, we'll go ahead and move on to our next session. So my name is Jed Kuhn. I'm at Vanderbilt University, and I'm going to ad-lib a little bit while we wait for our other panelists to come up. I know Rachel Frank is on her way over from arthroscopy, so she may be here in just a little bit. But we do have a great group of panelists. Rachel and I are moderating this session. Joe Abood and Grant Gergus, when they get here, will be up here as well. Your program says Lawrence Gulotta is going to speak, but actually Grant is taking over his role. This is the challenge that we have. Massive rotator cuff tears provide us with a lot of different options for treatment. We can do physical therapy. We can do injections. We can debride these with biceps release. We can do partial repairs. We can do partial repairs with graft augmentation. We can do superior capsular reconstructions. We can do tendon transfers, which include latissimus and trapezius and other tendon transfers that have been described. We can do hemi-arthroplasty. We can do reverse arthroplasty. And now we have a technology that actually has us put balloons in the shoulder that's relatively new. How many people have seen the advertisements or the product for the balloons? Just about everybody. How many people have used a balloon? A handful of people. Good. Well, I think that's still waiting to be seen what the role is. And some of our cases may get into that. But I think as a shoulder surgeon you have to have all of these tools at your disposal. Because it seems to me that every patient will present with different demands, different needs, and they will have different goals in their treatment. And you really need to have all of these tools at your access to match them to the patients appropriately. This is one way I kind of look at this. Our patients come to us with three or four different concerns. One of those concerns is pain. One of those concerns is strength. And one of those concerns is function. And so when we have these different concerns, you kind of have to weigh them and see which ones are more important to the patients than others. And our cases will present some of these different scenarios as we go along. I'm going to go ahead and start with our first case and then we'll let Joe join us when he gets up here. So this is our first case. This is a patient I actually just saw in clinic. This is not his picture, by the way. He looked like this. But this is a patient I saw in clinic over the past few months I've been treating him. And he's 62 years old. He's right hand dominant. He works as an operator in a cold mill, which is very physical work. And it's a very demanding, physically demanding job. His hobbies are demanding. He likes to restore cars. He likes to work on transmissions. He does a lot of heavy lifting and he likes to ride his Harley. And his chief complaint is weakness. He finds that he can lift as much as he wants when his arms are tucked in close to his body. But if he tries to lift something with his arms extended, he has some weakness. And he's talking about lifting up transmission parts. So this is a functional problem for him. It's really weakness. I ask him what percent of normal, we do a SANE score, and I ask this patient what percent of normal is your shoulder. And he says about 80 to 85%. He just doesn't like having that weakness problem that he has. So when we examine him, he's very fit. He's healthy looking. He's very muscular. You really can't appreciate any atrophy at all. And when you examine his range of motion, it's complete. You would not know this guy has a rotator cuff tear. When you examine his strength, he's very strong. He's very robust. He just can overcome my strength testing, except in external rotation with his arms tucked in. You can detect a little bit of weakness. And in scaption or super strength testing, just a little bit of weakness. You can look at his films and what we can see here. I'll ask my colleagues here to interpret. Dr. Bishop, what do you see on the films here? Well, I think on the AP, he's slightly high riding and he has a small osteophyte. You can see the arthritis on the axillary just a little bit better. So he has some joint space narrowing and a little change at the greater tuberosity, but not a lot. Anything else, Dr. Gergus? No, I think Julie nailed it. All right. So these are his films. You do notice a little bit of arthritis, which we'll be talking about later. So he's gone through some non-operative treatment. He's had injections with very little effect. He's had physical therapy. He's done it for three or four months without much effect. He still can't do that heavy lifting that he wants to do. And he says, I'm ready for surgery, doc. And so what's next? So I'm just going to review this with Joe, because we started a little bit early and Joe missed it. Sorry I'm a little late. I came from the other side of the country from ASES to this. That's all right. So Joe, this is a 62-year-old healthy, robust, really strong guy whose major complaint is he can't lift transmission parts out here. With his elbows and tucked in close, he's strong, he's fine, doesn't have much pain, full range of motion. You look at him, he's a muscular, strong guy. You examine him, you'd be shocked to find that he has a rotator cuff tear. So he's tried physical therapy. He says he's ready for surgery. So what's next? Well, I'll just tell you, we order an MRI scan. And this is what his MRI scan looks like. And Joe, if you want to, since you're here to the party, why don't you go ahead and let us know what you think about his MRI. Well, obviously very concerning. He has atrophy of pretty much every cuff muscle. Maybe there's a little tear he's minor left. He's got some early OA findings. So he's 46, you said? He's 62. Oh, 62? Okay. You want to just comment on the films or what I'm going to do? I'm sorry? Do you want treatment or just? Well, he's tried physical therapy. And his chief complaint really is not pain. It's not function. It's weakness. So we'll talk about treatment in a little bit. Okay. In fact, we'll talk about it now. What would you offer? Joe or me? In my hands, the most predictable operation, even though he's not, what's his subjective value score? His SANE score? 80, 85. SIU, suck it up. Anybody else have any comments? Grant. Yeah, so, I mean, I agree in principle. This guy is doing really well. He's got a very well compensated shoulder. He is doing the most out of that lower subscap and that Terry's minor just hanging on for dear life. And so I would tell this guy, listen, let's do some therapy to teach you some internal external rotation, strengthening exercise so you don't lose what you have. And you should seriously consider, is there another job you could go into? Is there something else? Because he's going to have it. It's going to tear further at some point. He's going to decompensate and then he's going to be in a real world of hurt. Dr. Bishop, any comments or questions on this one? You know, I think these are hard because first of all, this guy with that picture, he is not going to do physical therapy. He is going to look at you and roll his eyes and be like, I do therapy every day of my life in my job. We actually sent him to therapy and he did it for three months. Wow, that's impressive. Well, I mean, I'm in Ohio, but you are, you know, you're in Podunk area too. So, I mean, obviously I would definitely want to start with therapy. I'd be afraid to do a cortisone injection because I'm afraid that the cortisone, I mean, the tendons that he has, as Grant said, are hanging on for dear life. And I have seen way too many times the cortisone weaken then cause them to rupture and then they lose their function and then they are in a bad place. So I would really try to tell him, I don't think I have what he wants because if you did some big surgery, you wouldn't want him going back to that heavy job. And we recognize he has some pain, but it's not a lot. His real issue here is function. It's really strange. You could give him pain. You could give him pain and make it worse. And if I could just say, I mean, this guy has somehow magically retained the ability to raise his arm. And if you take someone like this to surgery and put them in a sling and disrupt whatever, whatever magic he's got working in there, there's a very real chance that he would be made significantly worse and pseudo paralytic after your operation. Wait a minute. I thought this panel had surgeons on it. You're telling me I'm just telling you I've been burned on very similar cases. Yeah. School. You wouldn't use a balloon Joe. What'd he say? Joe's a balloon man. Don't even go there. All right. So this is, this is the issue. This is a patient whose issue is strength. He has some pain, but not a lot, not enough to really warrant surgery. His issue is strength. So let's look at these different treatments that we have available to us. Which of these things do you think can predictably improve a patient's strength? Will physical therapy do that? Rachel? Yes. I think physical therapy can predictably improve a patient's strength. In this case, I don't know that you're going to get any stronger than he currently is after doing three months. What about injections? We already said, that's probably a bad idea. Maybe contraindicated for these, this patient. What about debridement biceps release? Grant, you already mentioned that going in there may decompensate him. I really, I've, I, when you have a patient that's this bad between this, well, there's such a mismatch between the MRI findings and the physical exam. This is a patient that you can make worse and you should be very afraid of this patient. So I'm going to go back to, to Dr. Frank here, because she had a, she submitted a case to me to be part of this presentation. It was something similar, uh, where she did a partial repair with graft augmentation. And there's a great systematic review in the literature now that looked at all these different treatments and actually graft augmentation did surprisingly well in the systematic review. And after reviewing that, I actually used that technology a little bit more than I ever used to for these patients. But Rachel, why don't you comment on that? Yeah. So I think, you know, in that case, it is interesting. I had a patient who actually came to see me for the contralateral shoulder chronic AC joints and he had enough of it and wanted it fixed. And on examining both shoulders, I noticed his right shoulder was completely weak and he had zero pain. He's like, oh yeah, I injured it over a year ago, but it doesn't hurt. Great active range of motion, but just no strength. And so we imaged that shoulder and he didn't have quite the atrophy that you showed on your patient, but a decent amount in the supra and infra. So we did the PT thing and we managed, and ultimately he said, you know what? I think I want my right shoulder fixed. I think this strength thing is real. And so I, I read them all the riot acts. I could make you worse. I could make you stiff. I could make you painful and stiff. And right now you don't have any pain. You have great motion. You're just weak. And ultimately we had that discussion and we went to surgery and I was able to get, um, if, if we can show you the video, but it's not in this case, but whatever tissue he had over called it a repair and put on a graft. Um, and he, he still has no pain. Thank goodness. Um, and at close to four months, he's happy as a clam and he's not strong, but he's getting stronger and subjectively he feels a difference in his shoulder. So, you know, if he doesn't follow up again, I can pat myself on the back and at a year I can tell you when he gets his reverse. Well, you made him better. That's a good thing. Now, tendon transfers actually transfer muscle, right? So do you think those have a role in increasing strength? I do. I think you can improve. Like if this patient had a, uh, you know, no arthritis and a better subscap and, and not the Hamada three that you've got there, I would consider if his main, when you show the history of just the chief complaint is some weakness and external rotation with the arm away from the body. That's where I thought you were headed. I found the lower trap tendon transfer to be very helpful in that situation. This patient was supreme surprising because when you measure his strength with his arms at the side, it's hard to tell he's got a cuff tear. I mean, you can really, he's pretty powerful. And if you looked at that Terry's minor, it was extremely hypertrophy and that's where that's coming from. Joe, any, any comments? You're way down there on that. You know, I think if he had less arthritis, uh, a little less function, uh, Boston describes it as the parachute technique, uh, doing the lower trap for the top and the latissimus for the subscap. Um, I don't have any personal experience with that, but that seems like a reasonable thing to offer somebody, but not this patient. So you were talking more about function, which is related to strength, but this is the guy that has good function. I mean, if you looked at him in the clinic, you'd say, you don't look like somebody with a cuff tear. He just has the complaint of some weakness doing high demand activities. So what about arthroplasty and somebody like this? He rides his Harley. He does heavy work. He's 62. His x-rays did show some arthritis. What do you think about, uh, a reverse or Hemi or something like that? Again, Mark Frankel has taught me that if someone rates himself above 50%, uh, I would not offer them a reversal of arthroplasty because I think they're not bad enough to garner the Delta for them to say afterwards it was worth it. So he's not a candidate for me for, for a reverse at this point. So it sounds like there's a consensus and this except for Rachel, uh, just kidding. Uh, this is what I told him. I said, look, I don't think I have a surgery that can give you that strength you're after. I said, when your pain becomes worse or you start losing function, come back and see me. And then we'll talk about options at that point. Well, that's case one. I'm going to have Dr. Frank come up and present case two. All right. Thank you very much. And I apologize for my tardiness. I too was running from across the state. Um, like to thank Dr. Spindler and Dr. Wright and Dr. Lee for having both Dr. Kuhn and myself here to do this case or do this case panel. So case two, um, this is a 50 year old male right-hand dominant who came in with a longstanding known diagnosis of a rotator cuff tear. He had a history on the opposite shoulder of three successful surgeries. And he has a history, excuse me, on that same shoulder of three, um, unsuccessful surgeries. And then a history of a successful cuff repair on the opposite shoulder. Um, he has painful activities daily living. He has nighttime pain and he has pain with overhead activities. On his physical examination, he has relatively normal passive and active range of motion, although active range of motion is painful for him. He has decreased strength to forward flexion and abduction, and he has some pain to palpation over the AC joint and biceps. These are his radiographs. Joel, what do you think of these when you take a look at this guy? Uh, humeral head's well centered. No significant, uh, disruption of Maloney's line. And no significant OA. He's got some sclerosis on the tuberosity and acromion. So pretty straightforward. Totally agree. So let's get to his MRI and I'll show you a couple stills on the next, but we'll let this, uh, scroll through. Um, and so, uh, Grant, what do you see? Yeah, so it looks like he's got a tear that involves at least the supraspinatus. I'm not sure if I saw the infraspinatus involved as well, but there is also a little atrophy or I should say fatty infiltration of the infraspinatus as well. So yeah, so it looks like it's kind of the supraspinatus going back and then, uh, infraspinatus muscle and fatty infiltration as well. Okay. So we have a chronic retracted rotator cuff tear, mild atrophy. What do we want to do? So he has pain. He has weakness. He has nighttime pain and difficulty with overhead activities. He's had a successful outcome on the opposite side. Let's say for argument's sake, he's tried physical therapy for three months and he is not happy with his current function. Julie, what do you think? What are we going to do for this patient? Well, let me backtrack just for a second. You said he had three prior surgeries. Were they all cuff repairs? He says cuff repairs. Okay. Yep. So there's no implants, there's no anchors, there's no tracks that we can see, but that's what he says he had. So, um, who knows? Right. Okay. And is he a smoker? Non-smoker, non-diabetic, the picture of Colorado health. And so I think obviously he's shown, first of all, a lot of times what I think is important is that he had a successful outcome on the other time, other side, because sometimes you wonder if someone's capable of a good outcome. But he has a good outcome on the other side. He's able to do well. He's able to heal. He has good function. I think it's great that he has good ER and subscap strength. So I think that you, based on what I've seen, I think you want to try to repair that, but you also have to be prepared for, because right there it looks maybe that you can repair that. So I think you need to see if you can repair it, if you need to augment or ultimately be prepared for an SCR. Are you having the discussion with the patient in the office, I might need to use a graft, I might need to use a patch, are you telling him or her, whoever the patient might be, about all the different materials that the patches are made of today? We have bovine, we have skin, we have synthetic, we have biologic, we have hybrids of all of these. Are you having that discussion or just saying when I go to the OR I have a toolbox and I open that toolbox for what I think you need? I'm probably in the middle. I don't think I'm quite as in depth, because I think the patient just sort of starts staring at you. So I tell them there's a couple different options. I think I briefly go through them and I say you've got to trust my judgment. Interoperatively I will pick the one that I think will give you the best outcome. Grant, does this MRI make you scared that you can't get that cuff repaired, given how long he's had his symptoms and how many quote unquote prior surgeries he said that he had? I mean listen, you never want to go into a surgery with just one plan and you know I do a lot of rotator cuff tears as everybody in this room does, but it's always nice to have a backup plan. So for this I'm having the conversation with the patient. Listen, I can see there's some atrophy that indicates that this has been there for a little while. I know you've had the prior surgeries, so this is not a straightforward case and ultimately you know we don't know how pliable this tissue is going to be until we get in there and do our releases and pull on it. And so I'm going to tell them about my sort of graft of choice and say hey listen I'm going to have this available. We may not need it, we may need it, but if we do I'm ready to put it in. And I think patients you know like knowing that you have a plan and a backup plan. Okay so I'd like to just ask with a show of hands with the audience, what would you do if you want choice A more non-op? Let's raise our hand. No one. We've got a lot of surgeons in this room. Okay choice B rotator cuff but no augment. Rotator cuff repair alone. All right about a third. Rotator cuff with augmentation. Now not an SCR but some sort of augment. Hands change a little bit. Okay about a third again. And how about SCR? Who's planning right away given that history, given that atrophy, given how wimpy that tendon looks for an SCR? No one. Maybe. No one. And then reverse. Anyone going the arthroplasty route? Anyone going balloon? I didn't include that here. Okay so what was done in this case arthroscopic evaluation, rotator cuff repair didn't seem to go so well. Tissue was just not amenable to coming over without very much medializing the footprint. So he got an SCR, distal clavicle excision given his preoperative symptoms and a biceps tenodesis because I was trained at Rush and there's no biceps that can survive a rotator cuff surgery. Surprisingly he had not had his biceps taken care of before despite having again reported three surgeries. So these are the intraoperative findings. So you're not a cable reconstructor? You wouldn't use that for your cable augment? So tell me a little bit about your thoughts on that because I'm not just based on my bias with my training but I'm very interested in using the biceps in that in that sense. What are your thoughts there Joe? You know I was in an ICO yesterday and Paul Sethi was talking about it quite a bit. Some of it's compelling as to you know consider using that. I mean it's you could use in different ways. You can leave it on the supraglottic tubercle. You can cut it like you did here and suture it into the into the superior tissue almost like a like an augment to the undersurface of the cuff. You know and some are tenodesing it and then tenotomizing it distally or tenodesing it distally or leaving it intact distally. It's really fascinating. I think we're going to learn more about it but you know it's it's something to consider and if you haven't heard about it a couple good articles out there to consider looking at. So let me ask you what would you do in this case with that biceps and with the knowing knowing the end result here that I recommended SCR chose SCR what would be your thoughts here just based on your feelings on the biceps and we'll go down the panel. Joe let's start with you sorry. Five years ago I would have done I would have done a tenodesis now I probably would incorporate it and do some sort of cable reconstruction with it. Grant. Yeah I'm gonna do a tenodesis it looks pretty tendinopathic there so I'm gonna do it super pecked but get a little kind of mid groove level to get away from that really bad section of the tendon. Julie. I do a subpeck tenodesis. Subpeck tenodesis. Jed. I would tenodesis it into the repair not like Joe did it as a structural thing but just tie it all together. Anyone in the room doing a biceps tenotomy? Leaving it alone. Maybe five ten hands. Who's doing a tenodesis? And then who's using it as some sort of augment for the rotator cuff repair? Okay so it'll be interesting to ask that same question in five years right with some of this data coming out it'll be interesting to see if the pendulum has swung. So we all know about SCR this is an older case but I'm now using more of a knotless construct on the glenoid and there are pros and cons to SCR and I think this outcome is dependent on your pre-surgical discussion with the patient. If you promise them complete pain relief and five out of five function and a sane score of a hundred you're gonna have a bad outcome but if you tell them what SCR can and can't do and you really pay attention to the pre-surgical MRI with regard to atrophy and you have a good subscap you may be able to get a very good result. SCR results are dependent on that discussion and that discussion I think is the number one thing and we don't really talk about that but I think patients outcomes depend on what their expectations are more so than anything else. Certainly you need to have to have technical expertise in the operating room. In these cases if you have any cuff left and then we'll kind of get done with this SCR case what are you guys doing with the cuff in these cases? I mean classically we're taught to repair the posterior cuff but I think now more and more of us are trying to repair as much cuff as we possibly can. Jed I see you nodding so let me let me what are your thoughts on this? I agree I think you know one thing that the SCR can do if you connect the two leafs of the cuff the anterior leaf and the posterior cuff it can create that coupled force and I think you get better strength if you can do that. Julie any thoughts on that? I mean I definitely believe in repairing the infraspinatus as well as I can I think that's important. I just think I know that there's definitely talk about repairing the what's left of the cuff over top of the SCR. I haven't been in a situation where I've had enough that I feel like I can get it over to the footprint for any kind of repair and if I can I'm probably doing an augment. So I probably haven't haven't done that technique but I certainly think there's validity to it. I share that struggle too I feel like if I have enough cuff to really repair over the top maybe I should have just repaired that cuff with an augment to begin with but I'm very conservative on SCR that they the cuff really has to force me to do that because we have so many other options and with some of the new augments my toolbox has really changed. Grant any thoughts? Yeah so just just to underline what Julie Bishop said I think it's really critical to not just give up and say hey let's put an SCR in there really take the time to do the releases and you'll find that you can always repair at least some of the cuff and I think that you know there's great data from Mark Lazarus and others on partial rotator cuff repair so at least take advantage of that. So let's say in this case you can only repair some of the infra and the supra can't be repaired fantastic well then I I'll take what I can get so I want to make sure I spend the time to repair as much of the cuff as I can. Joe let me ask you because I think the other part to this especially with the advent of the balloon and the implementation of that into our toolbox recovery is a big discussion with the patient because that changes the game what's your recovery for this patient what are you doing how long in a sling and when are you telling them their shoulder is as good as it's going to get? So for this particular patient in that procedure I would say six weeks in the sling typically I would say that they're going to be about 85 percent by five months plateau and improvement at a year to 18 months. So, you know, it's a long recovery. Obviously we all know that. They need to understand that to set up expectations. Anyone do anything different? That's essentially what I did, and I tell them it's a year, minimum a year. I think that's accurate, but I've found pain relief is really rapid, which is really nice. Patients love that component of it. Absolutely. I think we're running close to, do you want to zip through the next case before we, and then maybe we can, I think we're running close, I'm fine. So, again, with massive cuff tears, here to complaint is pain. We have a lot of different treatment options available, and you have to have these tools in your tool belt for it to work. So this is the third case. This is a 55-year-old right-hand dominant healthy male, pretty young, healthy, builds log homes, pretty physical work again. He has right shoulder pain, but really good function. He's out there cutting logs. He has full elevation, but it's painful. He has full abduction, but it's painful. When you test his rotator cuff, it's weaker, and this is his imaging. So, Joe, comment? So this patient looks like he has, you know, pretty significant femoralization of his acromion. He's abutting. He's got some OA on the AP at least. Would you call this advanced cuff tear arthropathy? I'm not sure. No, I wouldn't. Grant? Yeah, I wouldn't. He's got cuff tear arthropathy. You can see the, I mean, it's a monoform, so yeah. I would say it's cuff tear arthropathy, but I don't think it's advanced. It's all relative, I guess. I probably wouldn't say it's early, but I probably wouldn't say it's advanced. Early? Okay, well, regardless. He's had injections. He takes NSAIDs regularly. Tri-therapy no longer helps. He's finding it difficult to work due to pain. And so this is a patient whose chief complaint is pain. He does have some weakness, but he's able to build log homes, and his function is actually quite good. So which of these treatments would be best? Would you do a superior capsule reconstruction in someone with arthritis like this? Grant? No, for me, this is, I don't know where you're finding these guys. These are very challenging cases. Good for discussion. For this guy, again, I'm going to say, listen, your needs and the surgery that will address your needs are not well matched with you sawing logs. So for this guy, I'm going to talk to him about reverse total shoulder arthroplasty. He builds log homes, for crying out loud. And I'm going to say, listen, you can be the guy that goes out and does the estimates and supervises and helps out. He likes using that. This is Tennessee. He sleeps with his chainsaw. Listen, he can run a chainsaw, but he shouldn't be the guy lifting those giant spar poles there. So, again, you're just going to have to have a conversation with this patient. This is not a quick, hey, this is what you need, move on. This is one where it's going to be a little longer appointment. You're going to want to get to know this guy and know that you have his best interests at heart. And I think it's key that you ask him, what do you do for a living? A lot of surgeons just look at the x-ray and treat based on that. So I think that kind of conversation is really critical. You always have to ask what they do and what they do for fun. Julie, is there a role for arthroscopic debridement? That's supposed to help with pain. I know that there are papers that show that it helps with pain, but I would be really worried for this guy because whatever relief you got from that I think would be transient. He's going to go right back to doing heavy work and in three months be right back where he was. Joe, do you have an answer for this guy? I assume you have no other imaging, right? Well, I have pictures. Oh, okay. I'll just make it quick. We did not do this. Would anybody on the panel do a reverse on this guy? If he wanted to continue to do his work? Not with the scope pictures you showed, no. No. This is what I did. So I did a resurfacing hemiorthroplasty. I rotated it so it articulated against the chromium and did a biceps tenodesis. And I repaired it and protected his subscap postoperatively. He ended up with no pain. Regained full motion after three months. Returned to unrestricted activities. He came in ten years later, he's 65 now, with cuff tear arthropathy on the other side. He's no longer doing heavy labor. And we discussed a reverse, but he said, Doc, this one worked so well, I want you to do the same thing on the other shoulder. Ten years later. So one last thing and then we'll take a break. 87-year-old former right-hand dominant college football coach. Severe intractable right shoulder pain. Pulmonary fibrosis. Can't have surgery. Miserable case. Irritable. Can't move. Horrible imaging. Would anybody do this? Contraindicated. So the question I have, and I don't know balloons. I don't go to the circus like Joe. You inflate them and you pop them, baby. For crying out loud, what are the indications for this thing? Julie, have you ever used one? In this study, the indication is and was, and now it's labeling for the FDA is 65 or older. Minimal to no OA. Intact forced couple between the subscapularis minor. Typically, in the study, you could do concomitant work on the biceps. You could not do any labral work. You could do a chromioplasty or a dysclavical resection. I think if you keep your indications tight and minimally violate the bursa superiorly, I think it can be a good tool in your belt. I think if you start stretching indications like the last case you just showed right here, that would be a miserable failure. Well, that guy has no other options. SIU. He's 87. Thank you, Joe. What are the contraindications for a balloon? Arthritis, younger age, anything else? They have to be able to elevate their arm to 90. Obviously, any history of infection, that's a concern. And how much does a balloon cost? Is it cost effective? So, there's a HCPCS code coming out March 28th, which is going to provide reimbursement in the hospital setting for Medicare patients. So, it's expensive. MSRP is, I think, $6,500. But, obviously, everything is looked at in the window of cost. But if you look at it, forget cost for a second, as far as an older patient who met the criteria I just mentioned, it's a good option. It's minimal anesthetic time, minimal opioids with the opioid epidemic, less pain pills, immediate rehab, return of independence, less reliance on other people, return to driving, and meaningful contribution to society. So, there are a lot of indirect economic benefits. So, I'm waiting for the randomized trials to come out on this. I will not use it because of the cost. Question? Jed, this is just to back up what Joe was talking about with the long head of the biceps. I want to digress just for a moment because I think it's important. So, not in Rachel's case, but if you have a relatively pristine biceps with an L-shaped tear where the anterior cable is off, and we know the success rate for those repairs is less than with a crescent-shaped tear, I have used the long head of the biceps as kind of a scaffold to repair. And just as a point of note, biceps translocation for cuff repair was first reported in 1979 by Leonard Bush in JBJS, and there's a misconception that the Koreans, young girl Ri and others, were the first to introduce it. So, it's really a historic use for the biceps, and it can be very effective in that setting. Thank you. Well, we've run out of time. That concludes this session. Thanks to the panel, and the session will reconvene at 9.20 to discuss hips. Thank you. Good morning. We're going to go ahead and get started here on our hip session. I'm Mia Hagan from the University of Washington. I'm joined here by Dr. Mather, and we're excited to talk about hips. So, our first paper will be with Dr. Van Dome, predictors of return to sport in high-level athletes following hip arthroscopy for FAI. Thanks. Thank you very much, and glad we've had a moment to let all the shoulder and knee surgeons exit the room. We'll talk about predictors of return to sport in high-level athletes undergoing hip arthroscopy, and my disclosures are listed with the AAOS. Athletes clearly have unique demands, and the demands depend on the sport, and they dramatically differ from one sport to another. Hip arthroscopy has had favorable outcomes in athletes with high rates of return to sport, depending on the procedure done. A few studies have evaluated exactly why athletes fail to return to sport, and it's important to identify predictive factors for return to sport in the athlete population. So, our purpose in this study was to identify predictors for return to sport in athletes, to determine threshold values for significant predictors, and our hypothesis was that there would be modifiable surgical factors that would be predictors of return to sport. We looked at professional, collegiate, and high school athletes undergoing primary hip arthroscopy for FAI. Athletes were placed in two groups, those who returned to sport and those who did not, and PROs and patient variables were compared between those two groups. We also did a logistic regression and ROC curves. We had 136 athletes with mean age of 20.8, 66 pro in college, 70 high school, and overall return to sport rate was 87%, shown here in the pie charts by sport. The bivariate analysis identified seven characteristics that differed between return to sport and non-return to sport athletes, and there were two modifiable variables. First, the post-op alpha angle, and second, the change in the alpha angle from pre to post. So, then in return to sport athletes, we saw they achieved MCID for HOSSS at higher rates than the non-return to sport athletes. That's not surprising. And they had significantly higher post-operative scores. Again, not surprising. The return to sport athletes had a lower post-op alpha angle compared to non-return to sport athletes. The post-op alpha angle was the only significant predictor identified in the logistic regression model, and the ROC curve evaluating the return to sport based on post-op alpha angle resulted in a cutoff value of 46 degrees. We then looked at the odds of return to sport between those with less than or more than 46 degrees, and the odds of return to sport were 6.3 times greater in athletes with a post-op alpha angle of less than 46 degrees. So, to move on to discussion, the post-op alpha angle was significantly associated with return to sport, but there are some significant limitations of this study which I want to emphasize. The biggest one is that alpha angle is clearly an oversimplification of our femoroplasty. The perfect spherical femoroplasty is a complex 3D job, and alpha angle only captures one little bit of it. Other limitations, this was a single institution, and we always question the applicability from one institution to another. It did not assess the impact of CAM over a section, which we've shown to be problematic. And return to sport was treated as a binary outcome. They either returned or they didn't, so we didn't look at how long and how well and so forth. CAM management, in summary, is not a basic technique. It's, again, a complex 3D task, so we should consider it with the complexity that it deserves. This was rather easier when we were doing it with open surgical dislocations. If our goal was to achieve a perfect spherical femoroplasty, we used the spherical templates and made sure that we matched those templates. But with an arthroscopic approach, it's actually quite a lot harder because we're not seeing the whole sphere. We're seeing it in two dimensions, and we don't have spherical templates. So looking at an arthroscopic view of the globe of the femoral head is sort of like looking at the horizon from a view standing on the beach. We can't see that the earth is round when we're standing on the beach. However, if we have an x-ray view, then we can see the whole globe. So this is like looking at the earth from a view standing on the moon. Now we can see the entirety of the globe, identify what's round and what's not, and what we need to resect. There's still another caveat, which is that fluoro is a 2D perspective of a 3D shape. So if we're going to use fluoro successfully, we need to use it from many different angles to understand the three-dimensional shape. We published on the search for this perfect spherical femoroplasty and identified that this matters. The CAM over and under resections are both problematic, so we want a perfect sphere. In conclusion, post-op alpha angle was associated with return to sport in high-level athletes. The odds of return to sport were six times greater in athletes with a post-op alpha angle of less than 46 degrees. But although the alpha angle is a blunt instrument, it suggests that the quality of the femoroplasty may impact athletic potential after hip arthroscopy for FAI, and hence warrants our attention. To wrap up with a quote from Michelangelo, I saw an angel trapped in a block of stone, so I chiseled until I set the angel free. Thank you. Thank you, Dr. Dohm. Our next paper will be from Dr. Ian Clapp from Rush. The Predicting Clinically Significant Outcomes in Patients Undergoing Hip Arthroscopy for the Treatment of FAIS 5-Year Results in 453 Patients. Thank you very much for the opportunity to present. My name is Dr. Darren Konapik from Midwest Orthopedics at Rush. So as we know, hip arthroscopy has been shown to yield significant improvements in patient-reported pain and function, resulting in high rates of patient satisfaction at mid- and long-term follow-up for the treatment of FAI and labral tears. And with advancements in hip arthroscopy techniques and instrumentation, there has been increasing emphasis on evaluating patient outcomes based on clinical significance as opposed to statistical significance, with recent studies evaluating outcomes utilizing the minimally clinically important difference, the patient acceptable symptomatic state, and substantial clinical benefit. And there's been increasing interest as well in identifying patient and injury-specific variables predictive of achieving each clinically significant outcome measure. However, these studies have been largely limited due to short-term follow-up. And while we previously defined clinically significant outcome measure thresholds as well as achievement rates in patients undergoing primary hip arthroscopy with minimum five-year follow-up, the variables associated with achieving these outcomes at minimum five-year follow-up remain largely unknown. So the purpose of this investigation was to determine the variables predictive of achieving clinically significant outcomes in patients undergoing primary hip arthroscopy for the treatment of FAI with minimum five-year follow-up. To do this, we obtained IRB approval to perform a retrospective review of a prospectively collected database evaluating patients undergoing primary hip arthroscopy for the treatment of FAI performed by a single surgeon who had obtained preoperative patient-reported outcome measures at baseline and at minimum five-year follow-up, excluding patients undergoing revision arthroscopy or those for indications other than FAI, as well as eliminating patients with tonic-scary greater than one hip dysplasia or congenital hip disorders. Using previously defined clinically significant outcome measures and thresholds for MCID, PAS, and SCB, we first calculated the percentage of patients who were able to achieve each outcome measure and then analyzed over 300 patient predictor variables of which this represents a very short list of the preoperative, intraoperative, and postoperative variables analyzed and then performed by variant correlation analysis followed by principal component analysis to narrow our variables of interest, followed by multivariable regression to identify the variables predictive of achieving each clinically significant outcome measure. In doing so, we identified a little over 1,400 patients, and after applying our exclusion criteria as well as eliminating those with less than minimum five-year follow-up, we identified a total of 453 patients. And of these 453 patients, the mean age was 34 years with females composing 64% of our cohort and a mean follow-up of 64 months. When looking at the percentage of patients who achieved each clinically significant outcome measure, we found that CSO achievement rate ranged between 59% to 83%. When looking at the MCID, we found female sex to be a positive predictor for achievement of MCID while increased tonus angle and grade were negative predictors. Meanwhile, looking at the patient's symptomatic state, we found that female sex and increased preoperative HOS ADL were positive predictors for achievement while no negative predictors were identified. And lastly, substantial clinical benefit found female sex and increased preoperative HOS ADL to again be a positive predictor for achievement with preoperative back pain serving as a negative predictor. This study was obviously not without limitations, owing primarily to its retrospective design as well as a single surgeon series, as this limits the generalizability to other surgeons at other institutions, as well as limited our analysis to patient-reported outcome measures without accounting for other variables such as survivorship and return to sport. So in conclusion, we found that in 453 patients, clinically significant outcome measures were achieved in between 59% to 83% of patients at minimum five-year follow-up, with female sex serving as a positive predictor for achievement of all variables analyzed, while increased preoperative HOS ADL was a positive predictor for achievement of PAS and SCB, with increased tonus angle grade as well as preoperative back pain serving as negative predictors. As such, these variables should be considered when counseling patients regarding expectations at mid- to long-term follow-up for the treatment of FAI utilizing hip arthroscopy. Thank you very much. Next up, we'll be inviting Dr. Kneppel up to discuss anatomic hip labral repair. Good morning. Thank you to the program committee for the opportunity to present. I'm going to talk about anatomic hip labral repair. Here are my disclosures. So here's a typical case, 17-year-old with a significant CAM deformity, labral tear, early cartilage damage at a young age. So how are we going to approach this to optimize our patient's outcomes? So I'm going to hit on five common pitfalls in labral repair, joint penetration, adhesions, inadequate stability, inability to access difficult locations, and finally, labral eversion. So why focus on labral repair? As we just heard, hip arthroscopy outcomes are good, but there's still significant room to improve. Labral repair is a key procedure, and in primary surgery, it's going to be 50 to 100 times more common than labral reconstruction for most surgeons, despite not getting as much discussion. So poor labral repair techniques do play a role in persistent symptoms for some of our patients. Optimizing labral repair requires a focus on anatomic considerations, including patient-specific labral size and location of the tear to provide safe, reliable repairs. Early discussions of labral repair were focused on our options, knotless versus knotted repairs, labral base fixation versus circumferential fixation. And I think we now realize it's not a single approach that optimizes our constructs. So it may be different locations require different approaches, different surgeons utilize different things as well. The labral seal remains a key function of the labrum. This is in the biomechanics lab. We try to correlate this to our labral repairs to see contact and loading of the labrum after our repairs as a proxy, but we really don't know yet if that's truly restoring our seal. So to get to an anatomic labral repair, we need a stable construct compressing the labrum to the rim. We need to keep the labrum in an anatomic position without aversion, and then avoid other things that can damage our labrum down the road, like adhesions. Fortunately, we have better and better options for doing this. Smaller anchors, knotless, or all suture anchors, smaller suture passers, curve guides, all make this easier and easier to get there. You need to be aware of challenging labrums. So not every labrum is the same. Some are going to be more prone to issues. The hypertrophic labrum, the smaller hypoplastic labrum, also a challenge. And then tears that go more anterior or posterior are going to challenge our anatomic concepts. So our first pitfall is joint penetration. I think this is maybe the simplest to avoid. Distally-based portals like the DALA really help us here. If you're a two-portal arthroscopist, curved guides can help increase your margin for error. And then you still need to watch this. It's not just the portal, but settled issues with your guide can affect your issues with penetration. So you need to monitor this during drilling. Here we can see the increased safety zone with the DALA portal, making it easier to put these very close to the rim without penetrating. Here's a curved guide. With curved guides, it's very important to understand the trajectory of that curve, because this can be counterproductive if you're not using it in the perfect vector. We know from work of Brian Kelly, the 2 to 4 o'clock zone anteriorly is our highest risk. We certainly don't want to end up with issues like shown here. This can also be an issue with perforating the psoas tunnel with solid anchors. Curved guides come in a variety of constructs. The more distally-based curved guides are really going to probably help us the most. So while we're drilling these anchors, we need to watch the cartilage. Here's an example of detection of that bubbling. We need to stop drilling, redirect this anchor, use a different portal to safely avoid bigger issues. Our second pitfall is capsule labral adhesions. These are a common cause of revision surgery, and we don't really understand them yet. Young females appear to be at highest risk. Our capsule repairs appear to protect us to some degree. But technical considerations, including knots, play a big role. So here you see on the left significant knot prominence that's not going to be ideal for this patient's labral repair and can lead to adhesions as shown on the right. So minimizing adhesions starts at the capsulotomy. We really need to protect the capsule or leaflet proximally, elevating this off of the rim to allow us good tissue to repair at the end. Avoiding knot prominence comes down to two options, using knotless anchors or tying good knots. I think different surgeons have different preferences for those. We really need knot stacks to stay on the rim and the hip, much more important, I think, than in some other joints. So when doing this, I like to use knotted anchors as we get anterior where the rim is very small. A simple sliding knot, an under-under-over construct, allows me to put the knot on the bone and then tension my construct. So this is a hypertrophic labral. We'll do a circumferential repair here. So we're going to pass this right at the labral-chondral junction and then retrieve it. And then we're going to tie this through a cannula with a simple sliding knot. So this knot lets me put that knot right down on the rim. Hopefully I don't see it ever again. I'm going to tighten this loop, and then I'm going to add half hitches behind this. And I don't have an extra prominent knot, but just a simple half hitch construct. But I get the advantage of the sliding. So our third pitfall is inadequate stability. Labral-chondral stability appears to be a pain driver. Here's an example of a revision with a one-anchor labral repair. If you're putting one anchor in, probably not necessary, or you need to do more. The bigger labrum, the hypertrophic labrum, remains a challenge, especially as we see that in dysplasia as we combine hypertroscopy with those procedures these days. So here's a patient who subsequently goes on to a revision performed outside. Is this a stable repair? I think I'd argue probably not. It looks very similar to many tears we repair. Labral size plays a role here from the big labrum to the small labrum. That bigger labrum may require a more dense repair, more anchors to get there. So here's a hypertrophic labrum before and after. If we can get a nice compression of this, we can functionally decrease the size of the labrum there. You can see in the image at the end is a much more normal-appearing labrum. So our fourth pitfall is difficult-to-access locations. Fortunately, most of our tears are in easy locations to access. As we get more anterior or posterior, you need to be aware of having strategies to get there. So I like to think of this as slightly anterior and then those far anterior tears and then posterior and far posterior tears because that's going to change my strategy. Anterior tears, we need to respect the capsule anteriorly. It can be very thin and hard to repair. Small, all suture anchors can be protective of that psoas tunnel perforation as well. So here's an example of a revision with a capsular defect anteriorly. These are issues that we can avoid. When we work down at the 3 o'clock position or below, I like to go through a capsular window, so a percutaneous guide there behind the capsule. We can drill that anchor and then shuttle it back into the joint to tie and pass just like we did previously. As we go posteriorly, I think the concepts are similar. If we're going just a little posterior, I like to put anchors through the anterolateral portal. If we go far posterior, the posterolateral portal will help us. So here's a repair that's a little bit posterior. We have the scope of the mid-anterior portal, and our concepts are all very similar. If we get down far posterior, it becomes more challenging. This is actually a 9-year-old with a hip dislocation, interposed posterior labrum and transverse testabular ligament. So we're going to use an all suture anchor very low here to get fixation from a posterolateral portal. Our final pitfall is labral aversion, probably the most common error. The biomechanical consequences of everting the labrum I don't think are fully known. We know in the biomechanics lab it disrupts the seal. What does that mean for our patients? I don't think we know yet. We know in the biomechanics lab work I did with Mark Philippon that it really takes a perfect labral repair to restore the seal. Whether we're doing that clinically is hard to know. Avoiding labral aversion starts with anchor placement. You need to get your anchors very close to the rim. The smaller the labrum, the more important this becomes. So that hypoplastic labrum is at risk for aversion. Knotless anchors also have some advantages of dialing in the inversion and aversion tension, which I like for many of my repairs. So this looks good anteriorly. As we go posteriorly, I think that's an everted labrum. That anchor was placed too far off the rim, leading to pulling that labrum out. Knotless constructs with adjustable fixation can help us here. So here's a suture that's been placed. We're going to drill our anchor right at the edge of the rim. This anchor will fully seat. We put it in relatively loose. And then we can dial in the inverting and the aversion tension with the two limbs. So I'll pull first on the everting limb to make sure there's not slack in it. And then now as I tension the inverting limb, you can see the compression of the labrum right there. And you can really dial this in to get maximal stability. So here's some examples of smaller labrums that are a challenge to repair. But if you put your anchors in the right spot, tension this well, you can maintain the seal even with a small labrum. Often this may require letting traction down to really ultimately see if you've restored. But you should be looking at this on every case to kind of critique how you're doing. So if we return to our 17-year-old, we've used these concepts to put the labrum back in a good position all the way anteriorly from about 2.30 to 12 o'clock. And it looks like we've restored the contact with the head and loading of the labrum as we go to the peripheral compartment. So in summary, anatomic labral repair likely plays a key role in biomechanics of the hip. We've went over five common pitfalls with labral aversion probably being the most critical. A patient-specific approach to location and labral size, I think, can help you to optimize your outcomes. Thank you. Thanks, Dr. Kneppel. We'll now open to the floor for questions. Those were great. I encourage everybody to come up and ask some questions. I just wanted to note that this is the first time the hips ever had an AM slot, especially today. This is a big deal. Those were great talks. I've got a couple questions. Ian, one for you. Typically we talk about the MCID. You're more likely to achieve that when you start low because it's a change-based score. But in your study, you actually showed that you were more likely to achieve that if you started high. Can you comment on that difference? That's contrary to what we've known in the past. I think it's interesting. The answer to the question of why that is, I don't think we know. I think it just shows that there's a lot of variables to consider in these patients. It's really identifying those variables to whether or not what's really high, we're starting low. Is it female? Is it male? What's the degree of tonus? What's your tonus angle and grade? That's one thing that we did note and one thing that we've kind of put in our paper, is that this really requires a little bit of further analysis to really determine why that is. Dr. Dohm, I have two questions for you. I appreciated your comment that the alpha angle is an oversimplification of the morphology. So first question is, was version evaluated in that data set, femoral version particularly? And secondly, there's a lot of debate in the literature of what constitutes an elevated alpha angle, and you'll see different measures reported in different studies, insurers use different cutoffs, 50, 55. In light of your finding of 46 being the sweet spot, do you think that alpha angle should be lowered? These are great questions to which I don't think I have answers, but I'll give it a shot. To quote Gans, I'm a friend of no angle. So I think every angle is an oversimplification, every angle we measure. And alpha angle certainly is an oversimplification. I don't think there should be a threshold, and I put forth the threshold that's based on the statistics from the ROC analysis, but clinically, I don't think that is a useful threshold. I think what it does tell us is that the quality of the alpha angle matters, excuse me, the quality of the femoroplasty matters. And again, it's a complex, three-dimensional job. It's my personal belief and has been for a long time that if we're going to mess with what God made in the first place, the best thing I know to aim for is a sphere, and we can have a lot of conversation about whether it should be a sphere or not, but again, if we're gonna change what God made in the first place, I'll aim for a sphere. Now, how much of a sphere, how far to extend that? I don't think we have one number. Should it depend on femoral version? I think it probably should. If somebody's got retroversion, then we probably need to extend the spherical contour further, hence a lower alpha angle. We do look at our femoral version in all of our patients. We did not include it as an evaluated factor in predictors in this particular study, but in considering the femoroplasty, we always have that in front of me, that number in front of me, amongst others, and consider it in the femoroplasty. Hey, Ben, one question for you there, too. Do you think it's all about the alpha angle? We used to talk a lot about head-neck offset, and that's kinda gone away, that the whole literature now focuses so much on alpha angle, but when we're resecting, often we think that distal offset is important. How do you keep that in your mind, be weighing that? Yeah, it's a great point, and again, highlights the fact that alpha angle's an oversimplification. I do think offset matters, to your point, and I think we're, you can have a big over-resection and still have an alpha angle of 46 degrees, or a perfectly spherical resection and have it be 46 degrees, right? One's good, one's bad, but the alpha angle was the same. And similarly, you could have an under or over-resection distal to the alpha angle and have the same alpha angle. So, complex three-dimensional shape. I don't know a way to quantify the quality of a good femoroplasty other than to quote the politician about pornography. I know it when I see it. Ben, do you have a sense, in theory, if the higher alpha angles prevent a return to sport, that should happen more in high-flexion rotational sports? Do you get a sense that there was a difference among the type of sport in those patients? Probably insufficient sample size to look at that. Dr. Nepple, I enjoyed the technique video a lot. What is your feeling on chondral delamination and how that should be addressed in association with these labral tears? Do you try to incorporate that with your labral repair or leave it alone, do a chondroplasty with a microfracture? Yeah, I think cartilage is definitely something we gotta figure out more in the hip. De-bonding sort of carpet effect in the hip, we see in probably 60 to 80%. It's almost always there. In that setting, I think less is definitely more. Sometimes your sutures will sort of grab some of that cartilage edge and the continuity of the labral with the cartilage is intact. With true delamination, where it's a flap, I think microfracture is a great option. I think the outcomes of microfracture in the hip seem to be very good. I think I'm less aggressive about taking too much of it down, though. Sometimes as you start to open it up, the more you take, the more you continue to take. So being a little bit cautious to try to get to a relatively stable edge, but not turning it into a huge defect. I wanted to, I think we had time for maybe one more comment or question, but I wanted to ask Jeff and Ben and Derrick, how has your labor repair technique evolved over the years? I think that's important for a lot of people who are overall evolving, but as the field has evolved and we've improved things, maybe make a couple comments on how it's evolved in your practice. Yeah, so I think I definitely pay a lot more attention to the individual labrum and not trying to do the same repair in every labrum, that the big labrum's gonna get more anchors to get adequate stability. I think I probably focus more on adequate tension than I did early on, as well, to make sure it's a solid repair. I think sometimes repairs that aren't adequately tensioned set the labrum up to continue to have a further progression of the tear. And then I think looking at the tissue quality, as well, certainly there's been a lot of controversy around when tissue gets a little bit degenerated, should we be repairing, should we be reconstructing? I think I really focus on protecting the labrum during that early exposure to make sure you maximize the quality of that tissue, because in most cases, the labrum can be saved if you don't damage it during the process of getting it exposed. Yeah, yeah, not too much to add, but I mean, my biggest thing is just individualized treatment. It's not going in with the expectation, three anchors for every patient. It's looking at the preoperative imaging, it's looking at the location and the size of the CAM lesion to try and determine if there's gonna be an association with where that tear might be appreciated, and just doing a thorough evaluation and going in with the expectation that this could be different than any other case that I've done, and otherwise, the same tenets that Jeff just mentioned. For me, it's been a long journey with a lot of twists and turns, but there has been one lighthouse that has remained consistent, and it's a quote from an early biomechanics study out of Switzerland, which is that the labrum's sealing mechanisms are dependent on the fit of the labrum against the femoral head, and that has remained consistent throughout every modification or refinement we've made. So one of the earliest stabs at refinements that we made was our 2010 paper on labral base refixation, which, to be frank, at the time, I thought was a little nothing refinement, and it wound up kind of starting a big conversation, and I think a good conversation in our field about reproducing the anatomy of the labrum and the seal, and we've been through a number of refinements since then with the advent of newer technologies with tensionable knotless anchors. We evolved to be able to do the controlled tension anatomic repair, where we're wrapping the suture all the way around the labrum, but still making sure we don't evert it and maintain that labral seal. A lot of refinements, a lot of technological improvements. We stopped doing chondralabral separations for the most part, we did that early on, but the same lighthouse all the way through, the labrum's sealing mechanisms depend on its fit against the femoral head, and that's what we strive to reproduce. Well, great, well, I think that's a great way to finish it up, yeah. Dr. Mather. So, thanks, Dr. Mather, for noticing that we put HIP in the morning, and actually, if you come to the summer annual meeting, we have more than one HIP session. As we were putting this program together, and it's our 50th anniversary, we were able to put HIP in the morning, and it's our 50th anniversary. I know many in the audience have attended specialty days in the past where we've partnered with other societies, but we felt like for the 50th, we would go it alone and have a meeting without a partner, but in reflecting on the partnerships in the past, we felt it would be nice to have an address from every society that we've partnered with in the past. So, we've invited leaders from each of those societies to come and speak with us today about topics that blend between our societies and their societies. So, that's the goal for the next session. Kurt, you're going to introduce Dr. Deacon? Yeah. Thank you. So, our first speaker from the OTA is Dr. Michael Arch Deacon, and we're looking forward to his presentation. What we find in sports is a lot of what we do overlaps with other societies, hence we've partnered with him. So, we're looking forward. Thank you for joining us. Good morning, and I appreciate the opportunity. I'm going to spend a few minutes just bringing a few things up that I thought may be of interest to this group. My academy is updated in terms of my disclosures, which is in the interest of transparency. I'm a paid consultant for Stryker. I get research support from a number of institutions. I do some editorial work, and I have some leadership roles in some organized medicine. Most importantly, I've lived a very blessed life. I've been married to the same woman for 31 years, and I have four adult children. I consider that the most important accomplishment in my life. There's a picture of my lovely kids four years ago and one of my daughter's weddings, and I think in your world, that's called outkicking your coverage. So, I'm going to talk about clavicle fractures for a minute. I think this is an area you all see frequently and probably take care of as much or more so than we do in the trauma world. It's a 19-year-old male, patient of mine. He hit the boards in a hockey game when he was checked, neurologically intact, and he's likely to be drafted by an NHL team in about six months. So, he wants a good outcome in this particular problem. What does our literature say? Well, we've gone back over the last three decades, three and a half decades or so, and there's been some pretty good studies. And in general, mid-shaft clavicle fractures have done relatively pretty well. Some of the older papers, the Scandinavian paper, 82% asymptomatic if you let them heal, and they went on to union pretty well. Some had pain. There was some non-unions and some mal-unions, but nothing really all that bad. And I think most of us were pretty comfortable treating clavicle fractures non-operatively. Here's another paper from right before the turn of the century. And this was 242 consecutive non-op clavicle fractures, about 15% non-union, and about the shortening was significant for association for non-union. So, that started the change of advocating for ORF of severely displaced middle third clavicle fractures. Well then, in JBJS, Dr. McKee and Dr. Rosenberg published some nice papers looking at non-union rates, and what they found was that there was actually about a 15% non-union rate or so for non-operatively treated clavicle fractures. So again, starting to push us away from the non-operative, more towards the operative. And about 15 years ago, a nice paper, mid-132 consecutive fractures, op versus non-op, dash and constant scores were significantly improved in the operative group, but it's questionable whether they were clinically significant. Time to union was quicker with the operative group, and the non-unions really didn't occur very often in the operative group, but the non-operative group, again, moderate rate of non-union and malunion, symptomatic malunion. Nice paper from 2017, 301 consecutive clavicles, randomized to operative versus non-operative, again, constant dash scores increased and improved in the operative group, non-union around 11% in the non-operative group, and 0.8% in the operative group. So, where does that leave us? Well, here's my patient. This was a young guy. He's an athlete. He wanted to go to a professional career. We treated him with opioid option internal fixation. Couple years later, he showed up to our hospital after a car accident. He got a chest X-ray. You can see his clavicle healed nicely. He's playing some minor league hockey. I'm not certain what happened. He didn't make it to the big leagues in the hockey, but I think, in general, the clavicle fracture, particularly in the athlete, is probably gonna be treated operatively more often than not if they're significantly displaced or comminuted. What we don't know, at least we don't know clearly, is what about the patient that really needs overhead activity to be at its peak? So, like a pitcher, professional volleyball player, overhead, mechanics. I get a lot of mechanics that I take care of. I'd really like to have a sense of how that group does in terms of, is it more impactful for them to have an anatomic or near-anatomic reduction? And I don't think we know that yet. So, more to come, I think. All right, this is one I wanted to bring up to you all, because it's something you're gonna see as much as the trauma docs do in this particular circumstance even more. So, this is a 27-year-old male. He was from South America. He was playing soccer, and he had a collision, obviously a pretty hard one to get a segmental tibia fracture. He had consistent signs and symptoms of compartment syndrome. And he ultimately, he was splinted up there in the emergency department. He's taken emergently to surgery for decompressive fasciotomies. He ultimately gets his wounds managed. Here's his post-operative care. He had, we used a little reduction plate to help hold his proximal tibia and put a nail in. And then about a week later, he gets his soft tissue wounds managed. So, I thought this is an interesting paper. It's from about 10 years ago, and it looked at 626 tibia fractures over a period of time, and it looked at the cohort of soccer and football players. And 5% of all the tibia fractures had a compartment syndrome. But 55% of those injuries that occurred during soccer had a compartment syndrome, and 27% of those that occurred during football had a compartment syndrome. And I always felt that that was something that I never would have anticipated. Perhaps you all would have. But some of the idea was perhaps their muscles in a state of acidosis at the time of injury, and things like that. But it's not really clear why. But I can tell you that I now have a much higher index of suspicion when I have this low-energy tibia come in, particularly if it's somebody that was playing soccer. And I know you're not supposed to practice medicine by anecdote, but this has resonated with me and stays with me. So there's, he got his fasciotomies closed and his wounds closed up, and then he went on to heal, I think, pretty well. He never came back, and I didn't see him again. But I'm assuming he did okay, but you don't know with trauma follow-up sometimes. So the last thing we're gonna touch on this morning is low-energy S-tab fracture dislocation. So this is a patient of mine. It's an 18-year-old female. She jammed her leg during a field hockey game. She had a pop and the inability to move her leg, and you can understand why. She's got this posterior WASTAB fracture dislocation. But she was neurologically intact. And here's her CT scan. I just gave you some respective cuts. So I think this is not an uncommon injury. I've seen this in young football players, soccer players sometimes. And it happens, at least in my practice, I probably see three or four of these a year in patients under 15 or something like that. And the reason I bring this up is there's some literature and some thought that these can be treated nonoperatively, or how do you make your decision on treating them operatively? Obviously, this is not a significantly displaced fracture. It's a pretty small posterior wall fracture. What does the literature show? Well, Roy Moed, who unfortunately passed away a couple years ago, he did about 2,400 S-tab fractures over his career, and he really looked at this. So he looked at 33 isolated posterior wall fractures. They were assessed by examination under anesthesia to assess stability. And if the wall size was less than 20% of the wall, they were generally stable. If it was greater than 40% of the wall, they were generally unstable. But there was an intermediate group of 20 to 40%. And more so, where along the fracture line do you measure? Do you measure the maximum displacement at the level of fovea, high up? So even with somebody who's very interested in this, just not really clear. And if you look at the numbers, 18 of 33 stable on the exam under anesthesia, and 15 of 33 were unstable. 33% predicted stable based on CT were unstable. So what I'm getting at is it's not clear based on a static X-ray and CT scan, you may miss some injuries. And I would ask you to think about this like a Bankart lesion of the hip. Well, Dr. Moe had followed this up where he took what he called four expert acetabular surgeons, people who spent a lot of time reading about this, doing these surgeries, and he had them evaluate the CT scans and the X-rays. And they compared it to the exam after anesthesia. And only 53% was correct prediction based on these four surgeons who were arguably very well experienced in this field. Now, this is a nice study. It was published out of Harborview about six or seven years ago. 185 consecutive posterior wall estab fractures, dynamic fluoroscopic stress exam, or we call it EUA. Hip stability, 84% of the hips were stable. 16 were unstable during exam under anesthesia. But 23% of the unstable hips had a posterior wall size of less than 20%. So static imaging does not really appear to be accurate. And I think we all would agree that two hip dislocations in any young person is disastrous. And again, you're not supposed to live by the book of anecdotal medicine, but I can definitely recall a 12-year-old that I took care of, he had two hip dislocations, and unfortunately by 13 had osteonecrosis of femoral head. So again, resonates with me. Ultimately, hip stability after posterior wall is difficult to predict on static plane radiographs. An exam under anesthesia provides additional information to help determine that. Here's this patient of mine. You can see we did sort of a posterior wall labral repair and created a little what we call spring plates to help hold the wall fracture down. And there's the patient about a year later with a stable hip. At this point, no evidence of osteonecrosis or post-traumatic arthropathy, but we know that's a risk. So in summary, displaced mid-shaft clavicle fractures appear to have improved function in patient-based outcomes with operative treatment, and non-operative treatment has somewhere between an 11 to 15% nonunion rate. Tibia fractures after soccer or football injury or probably other athletic injuries have a higher concern or index suspicion for compartment syndrome. And finally, low-energy posterior wall static fractures, hip stability is super difficult to predict based on plane radiographs, and it probably is worth sending those patients to someone who does acetabular work and can do exam under anesthesia. Thank you very much. Thank you. Thank you, Dr. Archdeacon, that was great. Next speaker from the Southern California Orthopedic Institute representing the American Orthopedic Foot and Ankle Society, Eric Ferkel. All right, good morning, everybody. I just wanted to also thank Dr. Spindler and Dr. Wright for inviting me to be a part of this great meeting today. So I thought it'd be fun to talk a little bit about ankle fractures and synesthematic injuries, especially being a member of both societies. Is ankle arthroscopy the first step in treatment of ankle fractures? I would argue yes. So what is the role of ankle arthroscopy in the setting of ankle fractures? Well, it typically allows us to understand the pattern and extent of interarticular injuries in the ankle fractures, as well as really document any common pathology. The indications in my mind would be a minimal to mild ankle swelling with no neurovascular injury. It's also important to keep in mind to be quick and efficient in the OR. So let's talk about a case of mine here. It's a 30-year-old female who was dancing when she had an internal rotation injury called the POP. We see evidence here of a masoneuve ankle fractures location with a posterior malleolus ankle fracture and evidence of medial clear space widening. Under arthroscopy, you're able to really document and understand well the pathology where you see the syndesmotic injury as well as the posterior malleolus ankle fracture and really also allow you to open that fracture piece up and reduce that fracture fragment nicely. In my hands, this would be somebody out of scope and then fixate with both a suture button construct and a screw, as I believe this helps control both coronal and sagittal plane stability. So here we see the pre and post-syndesmotic scope films, pictures here where you see the reduction of the syndesmosis nicely. So let's talk about the syndesmosis a little bit. The syndesmosis is a dynamic structure and it's really important to understand that in over 45% of ankle fractures, we see a syndesmotic injury. Typically on history and physical, you see the mechanism of injury, gives you a little bit of a suspicion for the injury, a squeeze test, external rotation test, and then the question really becomes, well, does it matter? And we've seen from several studies that open reduction and fixation of the syndesmosis is absolutely important and that not fixing the syndesmosis can lead to poor outcomes. So when do we fix it? Well, evidence shows that when there's four millimeters of clear space widening immediately as well as concomitant posterior malleolus fracture and then MRI confirmation of a syndesmotic injury in a non-fracture situation does raise your suspicion to fix the syndesmotic injury. So it's really important to talk about how to fix it because placing the clamp is one of the most important aspects of maintaining the fixation construct. So a rate study out of Iowa showed in JBGS that showed that anatomic access of the syndesmosis in placement of the clamp, in malreduction of this and over compression can lead to an unstable syndesmosis. So the placement of the clamp should be at the lateral malleolar ridge, the central portion of the medial tibial cortex and one centimeter approximate of the joint. In the studies that showed oblique placement will lead to malreduction. So both in the C1 and in the A3 construct here on CT scan, this showed that there was malreduction. So placement in the B2 construct here was the most important for your clamp placement here. And you also don't want to over squeeze. It's important to understand that if you over squeeze and crush it, you can lead to a malreduction as well as articular surface compromise. So a great study by Dr. Gardner even showed that the amount of compression needed to squeeze an aluminum can was about as much as you needed to squeeze on that reduction clamp there. So now once it's reduced and understand the fixation, how do we understand that it is actually truly reduced? Well, you can look under arthroscopy and important to look under both intraarticular visualization in the arthroscope or you can make a mini arthrotomy and look at that as well. One study even showed that under an O-arm it's helped even understand the better reduction in the operating room further. So then once we understand that it's anatomically reduced, that what's the best method of confirming it, we just talked about the direct visualization, arthroscopy assisted in an O-arm. Well, let's talk about how do we fix it next. So here's kind of a nice timeline of the treatment of cytosmotic ruptures. Initially, the beginning of understanding this, talk about how many cortices, what is the screw size, what's the need for timing and removal. Then we kind of went on to, well, what's the duration of healing? And then furthermore, understanding what's the functional outcome and how does that influence their patient's return to sport. And now we've moved on to what is the benefit of ligament-specific fixation and the role of the deltoid in this. So a great study came out of AJSM several years ago showing that in a randomized controlled study here, comparison of suture button construct versus cytosmotic screw, with a two and a half year follow-up, that there was significantly less malreduction, recurrent diastasis, and improved functional outcome using the suture button construct. A recent study with a five-year result in the Bonin Joint Journal showed that there was better outcomes for both AOFAS score, the OMA score, as well as lower incidence of OA in patients treated with a cytosmotic button versus a screw construct here. So let's talk about another case of mine here. Here's a 40-year-old female who, if your clinic's like mine, you've been seeing a lot more pickleball injuries lately. It's pretty common in Los Angeles and in all age groups now, I would say. So she has internal rotation injury here where you see the fibular fracture as well as the medial clear space widening. So here's another great reason why I think we should scope the ankles. Under this, in this picture right here, you see that, you can see interop stress x-rays showing significant medial clear space widening. And then under arthroscopy, you see evidence of an acute osteochondral lesion to the talus, as well as you see in the bottom right view, the acutely torn AITFL off the tibia. So in my mind, we're treating this in several different situations. We're treating both the fracture, treating the cartilage pathology, as well as the ligament pathology here. And so with the cartilage pathology, we're treating this injury, mixing autologous cartilage with extra-articular matrix allograft scaffold. And then in terms of addressing the cartilage injury here, there's a great study in the journal Arthroscopy that showed that at the time of an ankle fracture, approximately 78% of patients were seen to have an acute chondral injury. Sorry. And there's a full thickness cartilage lesion seen in about 43% of these patients. 96% of these patients who had a chondral injury also had a concomitant syndesmotic injury. Now addressing the soft tissue injury here, I believe you can also furthermore utilize an anchor construct from the fibula to the wax staffs to Shaput's tubercle to further stabilize that AITFL. There's a study recently shown in FAI that described how using the suture anchor augmentation was helpful to decrease external rotation construct, as well as give a time zero strength resistance to external rotation. So here's this final construct here. So in summary here, the syndesmosis is important concept to understand in addressing ankle fractures. You combine the knowledge of the mechanism with location to understand and diagnose it. If there's obviously evidence of medial clear space widening or translation, fix it. If there is concern, get an MRI, or you can bring the ankle to the OR, I mean the patient to the OR and scope it. If they're obvious tear, you can boot and begin early weight bearing. Ankle arthroscopy, critical to diagnose pathology in ankle fractures here. Allows for treatment of the chondral injuries and loose body removal. You can directly visualize ligament injury, both the deltoid, AITFL, and PITFL, as well as addressing syndesmosis injury directly. In summary, I think the syndesmosis is not fully understood and is underappreciated structure. Don't forget about the medial side and the deltoid. Syndesmosis instability is best judged arthroscopically in my opinion, and reduction is best judged with both a mini open arthrotomy, and possibly in the future even further understand it with the scope. And then in the future, I think even addressing the ligament injuries that we're seeing concomitantly will be possible using arthroscopic techniques. Thank you very much. Thank you. Our next speaker representing the Pediatric Orthopedic Society of North America is Ted Ganley from the Children's Hospital of Philadelphia. Thank you, Rick. All my disclosures are on the website. Honored to be for AJSM, the section editor for Pediatric Sports. Our objectives and goals are to highlight collaborative work of the AOSSM and POSNA members. AOSSM study groups have served as models for pediatric-focused study groups. I'd like to thank the program committee, Dr. Spindler, Wright, and Lee, as well as Minh-Coker for the opportunity to give this talk today. So above you see the gold standard models for us as AOSSM and POSNA members. And there's many outstanding research groups and interest groups that are not shown, including Pluto, Jupiter, Anchor, which are pediatric-based. I'll highlight Rock and Tibial Spine and how that collaboration may apply to us all, hopefully. Our goal is to climb that ladder of evidence. You've seen the classic evidence ladder that's shown behind the black rectangle. And this is a series of tibial spine articles that I've produced over a 15-year period, and they're at those low levels of evidence. There's a song, I have friends in low places, I always felt I had studies in low places. We'll highlight OCD to start. How did we get started, and how can this apply to you? We started with the clinical practice guidelines. We were asked, would you like to review 20,000 articles, spend weekends in Chicago, lots of conference calls, analyze, and then write on that data. And a few of us said, sign me up for that. And what that revealed is what we didn't know and needed to learn, and those are listed there, some very basic questions that we didn't know or understand regarding OCD. And also what we needed to do. In terms of reliability studies, we developed radiographic nomenclature and determined reliability, published that in AJSM. I'd like to highlight Eric Wall, lead author. We developed arthroscopic nomenclature, as shown here. And then determined reliability, published that in AJSM on the volume shown. I'd like to highlight Jim Carey from Penn, outstanding researcher. And randomized controlled trials, I'd like to highlight Ben Hayworth, who developed and produced transarticular versus retroarticular randomized controlled trial surgical study, which is soon to be published. In terms of prospective cohort studies, we currently have 1,400 patients. We're just gathered two-year data, and Children's Hospital serves as data coordinating center. Our goal is to evaluate our two, five, and 10-year data. We have a study produced January 2022, Carl Nissen. This is our first from that prospective cohort. It's a descriptive epidemiology study. We've listed all of the ROC members there. And I'd also like to, while I have served as president the past two years, I'd like to recognize Kevin Shade, Jim Carey, John Polowski, and Carl Nissen, our incoming chair for the ROC group, and in terms of their leadership. Moving on to tibial spine, I was asked to form a study group for that. And our goal was, again, to climb that ladder of evidence to larger multi-center studies and some centers shown there. And we serve at CHOP as a data coordinating center for that. Our current lead of that group, JR Cruz, noted among 385 patients 2.6% of the cohort experienced subsequent ACL tears. Henry Ellis, former lead, showed good reliability in terms of superior displacement but other radiographic measurements were fair to unacceptable. Justin Mistovich, case western, showed the pretreatment MRI, 45% had a concomitant injury. So high rates of other injuries shown with tibial spine fractures. Neeraj Patel showed no difference in rate of MRI or findings at surgery in private versus public insurance. Although it took a little longer to get the MRI if you had public insurance. Jay Lee out of Johns Hopkins showed that nonoperative care had a higher residual laxity and subsequent surgery, operative treatment had higher rates of arthrofibrosis. I led an article on the risk factors for arthrofibrosis and tibial spine fractures. You might find that on your boards this year. We noted significant predictors of arthrofibrosis were age less than 10, non-sport trauma related injury, concomitant ACL injury and cast immobilization. As a disclaimer, I do not write questions for the ABOS. That may or may not be on your test. Dr. Kashar showed tibial spine and tibial eminence fracture suture fixation in video analysis and won some awards for that. So this with collaboration of AOSSM and POSNA members shows that we were able to produce nine publications in 24 months which shows how our collaboration and diversity can enhance our productivity. That was further reinforced by our score registry 5,000 knee arthroscopy cases and active projects for that are on meniscal tear, ACL and regional anesthesia in pediatric athletes. And I think perhaps the most important slide as I think about this is among the AOSSM and POSNA members, reviewers, I've always loved to see the views of other reviewers over the past 20 years when I've reviewed articles. Bruce Rider certainly serves as our editor but I believe our philosophy is that sharing insights builds strong culture in our memberships. That's further highlighted by Dr. James Wee who's a member of study groups and is a member of our organizations who's in terms of advancing relationships and we believe without boundary. Hopefully we addressed our objectives and goals and I thank you for your time. Thank you Ted. For American Shoulder and Elbow Surgeons, Javier Duralde, Atlanta, Georgia, Peach Tree Orthopedics. Thank you Rick and I'd like to thank the organizers for inviting me to come speak. It's interesting to see how each of us attack this subject you know in terms of our relationships with the societies and I think that you'll agree with me that the ASES and AOSSM have shared a lot of collaborative efforts and a lot of members. I have no conflicts with interest of interest with this talk. So I did an adult reconstructive fellowship with Dr. Near, Dr. Biliani and went into practice and was fortunate enough early in my career that one of my partners was a head physician of the Atlanta Braves and they invited me to come on and so I started working with the Braves in about 1998. We were fresh off of that world championship. They have a great team, great stadium. This is my family about 20 years ago. They're all baseball lovers so it was you know combining activities of going to games and treating patients as well and I had a lot of mentors and I think this is very important and it's important to understand from your perspective and from our perspective that our fields are very different and so I depended on coaching staff, training staff, my head team physician at the time Joe Chandler to really mentor me in terms of how you take care of teams and even some players who were much more astute at telling you exactly you know what was going on and how to deal with it. So about 10 years later I became the lead orthopedist and I have to say that about 2007 I figured out what the hell was going on because when I first got there a player would come up to me and say I've got a certain complaint. I had no idea what was causing that complaint, how serious it was, what the prognosis was and how we were going to get through it and gradually over time and a lot of experience on the field I sort of got that and I think it's one of the benefits of being able to do a sports medicine fellowship is you have intensive training under a mentor you really get that before you go into practice and thank god we finally won another championship. So the evolution of my sports career I really started out by figuring out what the path of physiology and path of mechanics were these injuries and then learned advanced techniques both in terms of training and then also in surgery and then really discovered the secret treatments that put you cut above everybody else in terms of giving your players the edge. But you know ASES and AOSM have a shared history and sports medicine has always been a very very strong part of the shoulder and elbow society. Our third president was Frank Jobe who was a mentor for many of us and with there's overlapping practice patterns and interests between our societies and there's always been great collaboration and you've already heard about collaboration of your society with other specialty societies in terms of multi-center studies and those continue to be very important. There are many AOSM presidents with strong ties to ASES and advances in shoulder surgery and this includes just your presidents but within your ranks there are a multitude of people who've served as our presidents have been strong members of your society and I know that with many in the room I share sorrow and sense of loss for Champ Baker who died this past week and contributed greatly to both your society and ours. He was the first ASES member in the state of Georgia and he was the first president of our Georgia shoulder and elbow society and we're all going to miss him. So there's a lot of practice overlap between the people in this room and the people three floors down right now. We look at the instability surgery, cuff surgery, elbow ulnar collateral ligament work and certainly conservative treatment and rehabilitation programs for shoulder and elbow problems but there are significant distinctions between our societies. You guys take care of a lot of other joints that we have we don't pay any attention to and a lot of the issues I talked about in terms of sports conditioning and non-operative management of the player and then certainly there's some things that we overlap in. There's a lot of people in this room and in your society who feel very comfortable with shoulder arthroplasty and shoulder fractures and then you get to the more esoteric shoulder operations of muscle transfers and revision surgery and probably people in ASES do a little bit more of those than people in this room. So if you look at what the practice pattern is for the typical ASES member, you know it's a referral of complex primary and revision cases and you see cases like this it just keep getting better and better. You're trying to come up with solutions for them and if you ask the average ASES guy in a community well how would you describe your shoulder practice it's an alliterative phrase that is like this because you wind up getting the very difficult cases from everyone in your community and Rick Fisher who was at Ohio State in the 90s had the classic line of I am the cloaca for shoulder cases in southern Ohio because you tend to get cases a lot of them are disasters many of our own making infections following arthroplasty fractures and it just keeps getting better these things walk into your office and you're often looking at opportunities for limited goal success in these patients which is very different from what you try and do in the field of sports medicine and often you have the entire arm filleted open and at the end of the day you're asking yourself what am I doing here and have I really helped this patient or not and so if you ask the average ASES member what do you think the sports medicine guys do they're you know they're hanging out on the field they're joking around with players having a good time in the locker room and you know having fun but you know as you know and we know really that it's an extremely challenging field because of the breadth and the and the acuity and the the difficulty and the fact that you're really trying to do highly complex operations and develop highly operations on people with very very high demands on their joints so it's high profile high risk operations if this guy doesn't do well everybody in your town knows about it and so you know there's an added pressure due to that and there's long hours on rainy sidelines on weekends away from your family you know you see here's the here's the sports medicine doctor right there and he's the only other person other than parents of the players who's still in the stands at that point and so it is a challenge. There's been a lot of cross-pollination you've already heard from the other speakers today about you know the benefits of each group looking at problems differently. I look at the innovations we've had with with instability with bone defects and this is one of my favorite new operations Dr. Proventure taught us doing the distal tibial allograft and and also you know what we've learned from the suture bridge techniques from rotator cuff also from Dr. Elitrash that have really helped us in the management of shoulder problems and these translate not only to the athlete but here's a disabled patient with a head injury and did a bone graft on him and he's just happy as could be and functional can now use his walker and so these are operations that help not only the athlete but everyone else. So we look at our satisfaction with the results how do we rate ourselves and when we go home at night how satisfied are we with with our results of surgery? Well all of us if we get a poor result turn to an excellent result we're all happy with that but often the cases that we're seeing we have a poor result and we can turn them into kind of a fair result and despite that we're happy patients happy often they have good pain relief even though their function is not good and the challenge with sports medicine is you get a pitcher who can't pitch and then suddenly he can pitch 80 miles an hour and that's just not quite good enough and so you sort of feel like a failure because you didn't get that player back out on the field you didn't get him back you know as as good as he was before surgery before the injury but that's just the limitations of what we have it gives us some impetus to move forward but I think we can each learn from each other that that our results can be good and we have to be realistic about what's possible in each case and the important thing is that the patient remains the focus of our care it's a patient centered care both no matter what type of patients we have and we can learn from you that we need to strive for the best and and strive for normalcy in in our operative techniques and I think you can learn from us that sometimes it's impossible to get there and you have to be satisfied with what you can do and really be realistic with your patient in terms of that and sometimes limited goals are the best you can do and other times return to previous level of play should be your goal in that but the patient should always be in the center of that discussion and sharing with those those those talks so what are our evolution of our roles you know I think as time goes on our roles relative to the academy are changing and and we are the thought leaders and we are the creators and and teachers of intellectual property and the same thing goes for your group as it does for mine and we need to figure out how we're going to do that going forward and work in conjunction with the academy you heard buddy Savoy talk in his speech on Thursday about the importance of us all working together as a society and we really need to work together with a society to figure out how we move forward in terms of the management of all this intellectual property and what what role do we play in the education of our future generations again as you've heard from other speakers today there's great potential for collaboration multi-center studies and I think the answer to many of our problems are in big data and then we need multi-centers to be able to work on that we're already working with you in the biologics association to trying to bring that sort of voodoo type of field into science and really be able to offer that to our patients honestly and be able to to treat them in a new way so it's very exciting and I think we've got champions on both sides of our societies working towards improving our ability to treat patients with biologics and that's just one example of many in terms of fields of rotator cuff disease and instability in which we can continue to work together so I'll close this by congratulating you on your 50 years of success and we look forward to reaching that milestone ourselves and we look forward to our continued collaboration with AAOSM. Thank you. Now it's my pleasure to introduce the current president of ANNA, someone who partnered with us last year in a historic meeting in Nashville, Mark Gettleman from Southern California Orthopedic Institute. Welcome. Well thank you and it's great to be here and it's great to see ourselves in person again and you know as Javier just said you know we all took different approaches to this and you know we have a lot of crossover between our two societies and so the way I look at this is the the complement to our history and to the future. My disclosures are available on the program and in the app and I want to first congratulate Kurt on an incredible year. We've spent a lot of time speaking throughout the course of the year and I just offer congratulations and to Rick and Cassandra on a great program and on their annual meeting coming up this summer. First of all congratulations to AOSSM on its 50th anniversary. It's an incredible accomplishment when you think about where we were 50 years ago it's a big challenge. ANNA is also celebrating and I'm our 40th president and it's our 40th anniversary this year which will culminate in May and we want to thank AOSSM for being such a great partner throughout the years particularly with the collaboration that we've had most frequently. It's my great honor to serve as ANNA's 40th president and you know the partnerships that we've had have been great particularly the combined meeting we had with AOSSM this past summer as we started to emerge from COVID in Nashville. ANNA's mission is is similar in a lot of ways but we specifically focus on the art and science of arthroscopy and minimally invasive surgery and we really focus on advocacy, skills assessment, and education and our goal is to really stick to being a visionary leader in arthroscopy and minimally invasive surgical education. For us we've got 6,000 members across 80 countries and represent an international community a lot like AOSSM and I think the key to all our successes as societies is working in unison with these organizations actually actually worldwide to improve patient outcomes and I think ANNA and AOSSM share many common goals and have been successful for those reasons. If you look at the cornerstones of success for a society I think they're similar for both of us. Education, leadership, membership, research and advocacy, and collaboration I think is equally as important to be successful. If we look at these certainly we've all been successful for different ways. I'd like to recognize Howard Sweeney who passed away last year and others for developing the OLC where we had the first course in 1994 and it has been a great source of collaboration over the course of the years. Certainly there have been advances in education looking at the fast technology or fundamental of arthroscopic skills training and we use that now to train residents across our programs for years. We're focusing a lot on proficiency based progressive training started by Rick Angelo our past president and really trying to work with the ABOS as well to try to determine a way to really say that we are proficient in what we do aside from just in a textbook. Leadership is key as well and we grew out of a course in 1975 from the American chapter of the International Arthroscopy Association and have a journal as well and congratulate Bruce Rader and everything he's done for the AJSM. We started an education foundation which allows us to work as a non-profit to continue to grow and work together with other societies and membership has been key and you know some of our forefathers did a great job to create ANA about 40 years ago and the membership has grown from 150 members in 1981 to over 6,000 across the globe and again allows us to be a great collaborative organization to work with members here today in AOSSM. A lot of things that we share and come from you know what happens in Washington DC and the adversarial regulatory environment adds stress to not only our members but your members as well and it's important for us to be able to continue to develop good quality care. Managed health care and maintenance of certification are also challenges for our memberships and we work together with our partners to really have things that have helped us move from ICD-9 to ICD-10 and the 2021 E&M changes to help us be successful in taking care of patients each day. The future for all of us looks very different. I think simulation, AR, VR are going to be critical. The OLC is a good place to look at this with the simulation room where we actually have simulators available and I think this will continue to be an important adjunct to education moving forward. The ANA-AOSSM relationship and collaboration has been very important and we've had many, many specialty days together throughout the year. The combined meeting last year in Nashville was a great success for not only our members but for industry as well and I think working together on the Biologic Association will help us establish the framework on what should be done in this new world. E-learning is critical as well, particularly during the COVID pandemic. It really gave us a way to continue to communicate with our members and, you know, offer some good education and help you challenge during that pandemic issue. Leadership, I think, is key and we have the faculty of the Arthroscopy Association in North America and we're using it in a way to kind of say that these are the people who have really demonstrated excellence with involvement, education and advancement. Lots of things that we need to look at and I think diversity, quality and inclusion are very important and I think they're a central focus for all of us across our committees and our specialty day program going on, you know, a couple of rooms down, partnered with RJOS for the very first time, the first society to partner with Ruth Jackson and we're very excited about that this year. Research and advocacy is critical for us all and I think it's important to have the funding we need and we're going to actually increase grants for research to make this more effective and I think we have to protect our codes and E&M management to allow us to be successful. Some of the online options are a great way to engage membership. I've seen it from AOSSM and us as well to kind of advance that research and help us work on the advocacy piece. Education revolves around innovation and I think you often have to have leading edge content and it's good for us to challenge each other to really keep an eye on the prize and make sure that we're looking for the best and the brightest. I think these new delivery methods are going to be critical to the future with VR and simulation and looking at proficiency based education will be important. It's really important for all our organizations to look at mentorship and it's really important that we look to our younger leaders to basically become the next generation of the folks who are going to be standing on the podium here today. I think the standards have to be high and we continue to try to push the arthroscopy journal just as you do with AJSM and we also have our open access family with Asmar and the techniques journal and I think if we continue to grow with our foundation as we're using our 40th anniversary campaign it's going to lead to greater successes for all of us. Diversity and inclusion need to continue to grow and we need to create a place that is good for everybody to feel comfortable to make a difference and I think most importantly we want to complement each other rather than compete as we continue to move forward. When we look at this we can do this collaboratively through outcomes and advocacy and I think there's great opportunities for us to move forward. I think as all these people you've heard up here today we have much to be proud of and we've done a lot of good for our members and our patients and I think that's key. We certainly look forward to future opportunities for collaboration with AOSSM to help better serve our growing memberships. I want to congratulate Dr. Spindler, the presidential line, the board of directors and the entire AOSSM membership on this 50th year anniversary. It's an incredible accomplishment and we were really appreciative of being here today. Thank you very much. We have a few minutes before the Kennedy lectureship so if there are any questions in the audience for the panel you can step up to the mic. Dr. Furkel, I'll ask you what about the moderate syndesmosis athletic spring? We don't have great grading classification scales but that grade two that moderate sprain that you know is going to take a month before they can or two months before they can really run, cut, what's the role for operative intervention in that when there's no obvious displacement but you know that they're going to be symptomatic long term? I think in the elite athlete there's definitely a role for bringing the operating room perhaps considering examination under anesthesia and if there is instability in that case then I would consider arthroscopic evaluation and then fixing the syndesmosis in those cases. I think in the perhaps the more weakened warrior type who doesn't have a rush to get back on the field we can consider managing unoperatively. And operative management would consist of in your hands? So in my hands currently I think I would still use suture button construct probably two divergent suture button instrumentation two divergent suture buttons. I think there is a movement though to fixing it with the reconstruction technique and maybe one suture button construct to both correct both the coronal and sagittal plane instability as well as manage the axial rotation stability as well. Chris? Chris Harner. Rick Curtin Cassandras is awesome. I think it's a tremendous idea and it's so great to see the organizations up here together and I want to applaud you for that. I'm going to ask a non-clinical question is that okay? Sure. So for Javier because I know we're all starting to look into big real world evidence big data and just a little bit of an update on their shoulder elbow registry and how that's going and I think trauma Mike I think you guys have started one too just some input on that and I'm sure that this has been talking at the AOSSM so if Rick and Curt have any input on that I'd like to hear it too. Well thanks Chris. It's going very well. I mean our registry you know we have one for arthroplasty also for rotator cuff and I don't have the numbers off the top of my head but it's going very well. We have some competition you know like a lot of groups are continuing to use OBIRD which offers a lot of the same sort of options as the academies and so some groups are having difficulty you know justifying the cost of being both of those but I think in either case there's large volume of data that's coming out. We are starting to make an emphasis in our multi-center studies outside of the registries as well and those are it's somewhat challenging in terms of funding you know because unless you're doing something specific that industry wants they're not going to fund it so we try and get funding for everything else and then use every penny we have left over to fund those and that's an area that of growth for us. Ted Kuhn's been one of the leaders in that field for us and continues to be so and so I see great growth in that area, great potential for growth and it's an area that we've probably not done enough in in the past. We've been doing our level four studies and I think it was a good topic talk that you know these low-level studies aren't helpful nowadays we need the better studies. I think similarly the fracture registry is pretty early and it's starting to get patients enrolled but it's probably one that'll span all of orthopedics because almost all orthopedic surgeons take care of fractures so as it evolves it'll probably generate a fairly large data set so U of T is excited about it and helping move it forward. Kurt any thoughts any comments in terms of what AOSSM is doing or been talking about? I think it's something being discussed now and and figure out where where it fits into that and you have to decide if the registry is meant for implant surveillance or is the registry meant for patient improvement and that's a patient reported outcome measurement and it's a challenge in an outpatient setting and it's a challenge for the academy. I'm putting my I sit on the raw committee of the academy so that these on supervising the registry so it's a challenge in an outpatient setting much different than an inpatient setting and it's a challenge when 50 percent of at least 50 percent of orthopedic surgeons are in small groups without an EMR how do you incorporate them into real world evidence too? Those those are those things will have to be solved. Thank you. I'd just like to follow up on that because that's a good question Chris and maybe Ted can give us some advice on on how the registries that you've developed how you've been successful with that. Yeah yeah was that for me okay um so I would like to say you know we um the leadership of AOSSM was a huge boost for us uh and and I would say that those people wear braces say what WW what would Jesus do and we tend to say what would uh Kurt Spindler what would Rick Ray do and Jim Carey can you check with those guys on a question we have so so their their guidance was tremendously helpful for us um and so we patterned you know our study groups um after that and so many of those members are so uh getting advice from active AOSSM members so um I don't say we have a any kind of magic uh formula with that um and our groups are not as as as large as the as the Mars registry or you know like which which is inclusive of all AOSSM members I don't even know how you how you did that. We did it with AOSSM backing and offered it to all members and ended up with you know 80 people more in private practice than in academics so it was a real testament to to the people in this room and the sport uh um and we were building of course on Kurt's work with Moon but uh yeah it's it was it's great and the society backing was uh critical. Yeah it sounds like uh um these collaborations and partnerships are key for the registries and you need to have the champions through um the study groups or task forces with the collaboration with the larger organizations and their expertise and resources so congratulations for for the efforts that are going on there. Well thanks to the societies and thanks to the speakers uh I think this was a great session uh really appreciate your uh contribution. Thank you. One of the most fun things I get to do all year and um is really get to pick the Kennedy lecturer and it's a great honor uh to pick the lecturer and it is uh it is a great pleasure to introduce him and so the Kennedy lecture was established in 1985 there's more details in your handout by the Kennedy family endowment in the American Journal of Sports Medicine and Jack Kennedy was an AOS founding member of AOSSM in 1972 president in 1979 and basically the lecture in the honor of his outstanding clinical educational and research accomplishments in the field of sports medicine and orthopedics. So this year's Kennedy lecturer is Chris Kading he's a master team physician he's been at OSU for 30 years he's a team builder he's built an outstanding and a huge program in Ohio State sports medicine and he's been a great team player I've known him for many years in Moon Mars and in Bear Moon. He has many many accomplishments and I just wanted this is my interpretation of the highlights of his accomplishments. He's the Judson Wilson professor of orthopedic surgery at OSU in the College of Medicine. He's the executive director of OSU sports medicine medical director for OSU department of athletics. He's been the godfather of the AOSSM traveling fellows to the Asia Pacific in the arthroscopy and sports medicine society. He has been the Ohio Athletic Trainers Association team physician in 2017. He's been president of the ACL study group. He's won the Kappa Delta Award twice. He's won the O'Donoghue Clinical Award twice. So it is my pleasure to introduce Chris Kading to you as our Kennedy lecturer. You actually get a little gift, two little gifts here, so you can open them later, so thank you. Thank you, Kurt, for that kind and generous introduction. And I also want to thank AOSSM for allowing me to be up here today. It's an incredible honor, and quite frankly, I'm very, very humbled by this opportunity. I'd like to also recognize Dr. John Kennedy, the namesake of this lectureship, and recognize all his work and efforts at advancing our field of sports medicine. He was an exceptional mentor to many, many people, and I think we'd all benefit from emulating him. When I was thinking, what do I want to talk about in this presentation, I really thought about it quite a bit, and I was struck by a couple of things. One is, life is busy. It's too busy. Everyone in this room has at times felt overwhelmed by all the activities we have in life that demand our attention, right? We're all struggling with this proverbial inbox that's constantly refilling and replenishing and overflowing with demands, requests, and requirements of our time and energy. And those requests come from various individuals, various organizations, and quite frankly, if you look at it, a lot of those actually come from ourselves. A lot of this is self-generated. We're all very, very busy. In fact, we're so busy in this treadmill of life that a lot of times, we don't have time for reflection. But there are events in life that I think force us to hit that red stop button on the treadmill and force us to pause and reflect on life. I've had two of those events recently. One was the passing of my parents. It's never easy to lose your parents, and those out there, those of you who've been through it, you know what I'm talking about. I think the passing of one's parents is one of life's sentinel moments, and I can't imagine whether you were close to your parents or not, that one losing your parents doesn't result in significant introspection. The second event was the birth of my grandson, our first grandchild. My son has a son. That kind of blew my mind. And the first couple of times I held my grandson, they were very powerful moments, much more so than I would have ever anticipated. So you can imagine the juxtaposition of these two events, you know, generated a great sense of the circle of life. Life is precious, and our time here on Earth is actually quite short. So when you start thinking about these kind of ideas, obviously the next question that pops up, what should I do to maximize this gift of life that we've been given? So that's not an easy answer, right? We've all at some point thought about that, but with those two events, I thought quite a bit about it, and as I'm pondering these questions and issues, I would hear people make reference to this concept that kind of caught my attention. Work-life balance. Seems like a noble goal. Seems like it's appropriate to what I'm thinking about. I'd hear people say, I don't want to work too much, I want to enjoy my life. I want to live my life, not just work. He works a lot, he has no life. So it made me think, you know, what exactly is this work-life balance thing, and how does it apply to me? How does it apply to us? They seem to imply that work is this unfulfilling, tedious activity, and that life is rewarding and meaningful, and that there's tension between these two. So is work that for which we get paid? Is it always negative? Is life everything else? And is it always rewarding? Is work distinct from life? If so, if the answer to all these questions is yes, well then, it struck me the answer's pretty easy. Don't work. But that doesn't seem to be the right answer for us. So the more I thought about it, the less I like this term work-life balance. It didn't reconcile with my personal experience, it didn't seem to apply to me. What is work, what is life? Is there a clear distinction between these? Is one a necessary empty chore, the other all blissful happiness and reward? I'd have people say, Chris, you've got to stop working so much, you'd have to play some golf. Okay, that's great, I think, but I think it's playing golf more rewarding than having a grateful patient. And I've got nothing against golf, except keeping the ball on the fairway, getting it on the green, putting it in the hole, but other than that, I think golf's great. But I get great satisfaction from mentoring people, a great sense of contribution when research you're involved in impacts clinical care, enjoy seeing any program I'm associated with grow and improve, and these are all work-related items, but they seem to be, they are a great source of personal reward for me. So I had this revelation, we've been blessed. Our vocation is not a negative, unrewarding, soul-draining ordeal that's required to live. It's quite the opposite. For the most part, I enjoy what I, quote, do for a living. Advising patients, building a program, doing surgeries, covering an athletic team, and what is more rewarding than a heartfelt thank you from a patient? I believe that every human being seeks social interaction and relevance. Really, who wants to be isolated and irrelevant? And any vocation that makes you feel isolated or irrelevant is indeed soul and spirit draining. Fortunately, ours is the opposite. We have lots of opportunity for interaction and doing something that's relevant. So this distinction between work and life blurs. You know, is covering your child's football game, is it work or is it life? Several years ago, my wife and I had the opportunity to spend a two-month medical service trip to Zorzor, Liberia, phenomenal experience. Clearly work-related, but in this work-life concept, it had a huge aspect of life to it as well. Wayne Woodrow Hayes has this famous saying, you can't always pay back to those who helped you in the past, but you can always pay forward to the current and future generation. When I hear someone reference that quote, I always think back to this Liberia experience my wife and I had and how it was a real blending of work and life. So if this work-life balance concept, you know, it doesn't work for us, yet there's something there, right? We all feel some tension in our life, so what is it? If it's not this work-life balance, at least the way a lot of people define it, well, I think our dynamic is different. In our dynamic, work is not unfulfilling and tedious, it can be very rewarding and meaningful. And instead of work subtracting from our total life reward, it can actually add to our total reward. So instead of this tension between a positive and negative that the traditional view of work-life balance is, we actually have two positives, rewarding work and rewarding life. But wait a minute, work and life, I don't like those terms either. I don't think that's right. I would suggest that we replace work and life with professional and personal, both of which can create satisfaction and reward. So our dynamic is we have to look for this ratio between professional reward and personal reward because our total life reward is the sum of our professional and personal. Now, a professional reward, it can be, I divide it into extrinsic and intrinsic. Extrinsic reward professionally can be financial, it can be national, local recognition, it can be a career advancement, it can be awards and recognition. Intrinsic award can be the grateful patient, it can be a mentee saying thank you or the internal satisfaction of the health patient, a well-done surgery, relevance research, programmatic growth and advancing our field. So I get asked quite a bit, no, Dr. King, what do you enjoy most about your job? And when I think about that, there's no one aspect of my job that I enjoy the most. The fact that I enjoy the most about my job is it's so multifaceted. Obviously, in clinical care, I take care of athletic teams, I'm involved in local organizations, I do some consulting, some product development, involved in national societies, I'm in administration, I do some teaching, I'm pursuing programmatic growth, involved in some research, and I do fundraising. I enjoy all those things, and I know two weeks in my professional life are the same. Clearly, orthopedic sports medicine is not unidimensional. We have multiple aspects and dimensions on which we can focus, on which we can achieve professional satisfaction and reward. And there's even more great news. You don't have to pick just one of those facets. You can do two or three or four of them. And your selections can evolve and they can change during your career. Sounds pretty good. Is it too good to be true? Well, there are challenges to this. No, it's not all good. As I've gotten older, I've become a huge yin-yang guy. Every yin is a yang. Every benefit comes with a cost. I'm a big believer in that. And our vocation is a huge benefit. So, you guessed it, there are challenges to this. One challenge is, quite frankly, I just described the endless opportunities for professional fulfillment. These can overwhelm our personal efforts. We can have a black hole of professional fun and rewarding activities. They can take all our time and energy from our personal side, take it away from our friends, our family, and personal health and wellness. Orthopedic sports medicine could be like the mythical Greek sirens that can lure us into tragedy. And I'm sure everyone has felt this draw to spend more and more of your time and energy on your professional side. Another challenge, the positive feedback loop trap. The more you give, the more you get. And the more you get in one activity, the more you tend to give it. This occurs in several areas on the professional side. And a corollary to this is dabbling, right? That's like the negative feedback loop. It doesn't work well on either side. I'm gonna do some research. I'm gonna dabble in it. I'm gonna spend one or two hours a month maybe doing some kind of research project. I'm gonna be a team physician. I'm gonna go to the training room once a month to see how the team's doing. I'm gonna be a surgeon. I'm gonna do one or two surgeries a month. Personal health, I'm gonna go to the gym once or twice a month to take care of my personal health. I'm gonna pay attention to my wife and kids once a month or so. So dabbling just doesn't work. So this positive feedback loop, the more you give on one side, the more rewarding it is, but the less you have for the other side. There is a zero sum game here, which is a challenge. So this is not an easy situation to optimize, right? This situation does not naturally find an equilibrium. Positive feedback loops don't lead to equilibrium. So this black hole and siren of our professional efforts can quickly overwhelm the personal side and lead to some tragedy on our personal side. So we only have so much time and effort on this earth, we clearly must be very thoughtful on how we expend it between our professional and personal lives. We need an active assessment of the time-effort ratio between our professional and personal lives. There's no clear or single correct answer. In fact, I think the answer's a process, not a result. We must intimately make a hard stop in our lives and perform a purposeful assessment of our effort ratio between our professional and personal lives. This has to be a hard stop. This isn't, oh, you know, driving to work today at the red light, I kind of thought about, you know, maybe I ought to do a little of this. No, you need to be very thoughtful in this, I'm going to come back to that. And it needs to be done repeatedly. One time going through this process is not going to do it for you. Your situation on either side can change, the reward that we seek can change, and you can change in your stage of life. And there's more traps that we have to deal with, all right? You can fall in the, oh, I'm too busy to think about it, I'll get to it tomorrow. You can be a momentum rider. Hey, my life seems to be doing pretty good right now, I'm just going to keep riding this momentum, the next 10 years the same thing I've been doing the last 10 years. I think that's a mistake. You can be following external guidance. You can be putting your time and energy into something that someone else is telling you what you should be doing. Oh, you can fail to recognize that every benefit has a cost. And of course, there's always hubris. One of my favorites, it's kind of subtle. Hubris is excessive pride or self-confidence. You know, it doesn't sound like an orthopedic surgeon, right? You're thinking, I can manage this, these challenges aren't going to affect me. I'm too smart and capable to fall into any of those traps. It's not going to happen to me, it always happens to the other guys. Well, hubris has been the demise of many a soul. Now, this next is a little video that one of our PhD researchers made. And it kind of reminds that, you know, humility is right around the corner and life is not always glamorous. ♪ It's all you got, so I'll take your best shot ♪ So, this is a game we're in white. We play in Iowa, and this is our star quarterback. And this is me, and I get knocked right over the fence. They love showing that apron over there. I go over the fence, feet are in the air. And all the players come running over. Of course, they go over to get our quarterback. And they left me turtled between the bench and the wall. I'm sitting there, I see my feet, and I see the sky, and I'm stuck in there, and nobody's apparently coming to help me. And some of the fans lean over the wall, and they're like, dude, man, you got blown up. And they're like, help, blow me up. So, life's not always glamorous, and humility's always right around the corner. But we've been given a great gift, but with that gift comes some hidden cost, right? So, we need to recognize that we have a gift, and it has hidden costs. We need to be grateful that we have the gift, and we need to be purposeful on how we deal with those challenges that come with that gift. So, I'm going to propose a six-step plan, all right? Six steps on how to try to find some balance between your personal and professional. Step one, find professional reward opportunities. Now, there's an aspect of our vocation that is tedious and unfulfilling, but look in your professional life, what will make your work interesting, rewarding, stimulating, or fulfilling? We've talked about there's many, many areas that you can look into, and I think you need to stop, pause, think about what are the professional areas that I could put some effort into that would make my professional side much more rewarding. Now, studies have shown that regardless of your profession, when you're young, your professional goals tend to focus on attaining and acquiring. You want to attain or acquire money, reputation, professional advancement, those type of things. But as we age, our professional goals tend to shift more toward relationship-oriented goals, such as giving back, making a difference, or leaving a legacy. So be aware of that. As you go through life, your goals, priorities may change. Identify, step two, identify your personal reward opportunities. Is it family? That's an obvious one. Is it personal enjoyment, your hobbies? Is it your personal health and wellness? Is it friends? Is it some social organization, your church? And then, obviously, your personal situation is going to evolve in time. The obvious one is your family situation, but other things can change as you go through life. Step three, you need a brutally honest assessment. What do you really want from your professional life? Not what someone else is telling you you should do, not what your mentor, your spouse, your friend, your teacher, your peers tell you. What do you want out of your professional career? You need to put some real thought into that. And what are your personal life priorities? So step three is a brutal, honest assessment. And this is an honest list of your personal and professional priorities. All right, so now you have this very audacious, ambitious, robust list of prioritized list of your life goals, right? You're gonna do all this. Of course you do. You've got 15 pounds of life goals that you're gonna try to fit in a 10 pound sack. So can you fit your list of personal, professional priorities into a 24 hour day? I'm guessing no way. So you're gonna have to redo your priority list to fit your time, energy, capacity. And you have to recognize that a gain here can be a cost there. Again, efficiency aside, we've got a zero sum game here a little issue. So you're gonna have to trim your list. That's step four. Step five, things are gonna change. Recognizing your situation and priorities will change. So you need to plan another hard stop. And in that hard stop, you have to repeat steps one through four. You have to do that intermittently. Step six is not gonna be perfect. And recognize that your list is not gonna be perfect. Don't fret about this, that it's not perfect. We don't live in a perfect world. Be satisfied that you're thoughtful and proactive at how you're spending your personal time and energy. And that's doing more than what 99% of everyone else is doing. So in summary, the six steps. Define your professional opportunities. Define your personal life opportunities. Do a brutally honest priority list of which of those you want to pursue. And remember, you can't do everything. Revisit the list, trim your list. Recognize that things will evolve. You need to reevaluate and intermittently have to repeat steps one through four. And accept and be thankful. It won't be perfect, but it will be thoughtful. Now I'm gonna shift gears. How do you maximize reward on either side? Well, on the personal side, far be it from me to tell you what to do on your personal side. You're on your own for that. But I have a couple thoughts on the professional side. First one is team. Kurt made reference to that. Team, a group of people performing interdependent tasks to achieve a common mission or goal. All right, we've all seen teams at work. John Doan, a poet and cleric from England said, no man is an island. None of us is where we are today without some help or interaction with multiple other people. And the fact that we don't function in a vacuum is just reinforced by someone like Isaac Newton who had some incredible, unique insights and innovative thoughts. He admitted that if he's seen further, it's because he stood on the shoulders of others. So although I'm telling you, let's embrace, encourage you, embrace others in your professional journey. But, yin-yang, working with people is not easy. Building a team is a challenge. Building a high-performing team is a huge challenge. So what are some of these challenges? Agendas, does every member of your team, do they have a personal agenda that jives with your team agenda? What about the level of commitment of your different team members? What about personalities, complex human interaction? What about credit? Don't underestimate the issue of giving credit when your team has some successes. What about the perspectives of your individual members? They can be different and that can create tension. Skill sets, every member has the same skill set? No, they have different skill sets. Are those appreciated and recognized by everyone? Ego, self-explanatory. Trust, do your team members all trust each other? What about the logistics of, quite frankly, operating and functioning with several different organizations? Clarity of structure, if you don't have clear structure and rules of operation within your team, you're very likely to devolve into some chaos. What about priorities? So the priorities of the team, how well do they dovetail with your team members? So there's a lot there. Don't be intimidated, but also don't be naive as you go into working with a team. So being solo, simple, fast, easy, less complex team, more complex, but has infinitely greater potential. When I first arrived at my institution in the 90s, I was pretty much the only orthopedist taking care of the team. I was scoping elbows, scoping ankles, doing shoulders, doing knees. The primary care doc was doing all the family medicine stuff, doing psych counseling, nutrition counseling. We were doing it all. That has evolved into a very robust, multidisciplinary medical team now. We have five primary care docs, five orthopedists, four sports psychologists, two sports nutritionists. It just goes on and on. Now, I look back with fond memories of what we were doing in the 90s, but clearly this team that we have now is much more effective in delivering a higher quality product than what we were doing, although it's more complex managing that team. If you want to go fast, go alone. If you want to go far, go together. A lot of wisdom in that African proverb. So whether you're trying to climb a mountain or trying to understand some basic elementary particles of our universe, if you want to achieve something big, you're going to need a team. So a couple quotes from people who know something about success. Great things in business are never done by one person. They're done by a team of people. Steve Jobs. Talent wins games, but teamwork and intelligence wins championships. Michael Jordan. And I think my favorite, teamwork is that fuel that allows common people to attain uncommon results. Andrew Carnegie. So a team can be viewed as a high-performing interaction of moving parts, all right? And if you're going to build something that has a lot of moving parts, you'd be very careful in your construction, right? If you want it to be formed at a high level. And then that machine or team of moving parts is going to require diligent maintenance. So team building and maintenance, though challenging, can obviously give some incredibly rewarding results. Now, several years ago at the AOSSM Council of Delegates, we were dealing with the issue of team physicians crossing state lines to take care of their teams. And we took that challenge on, and the Council of Delegates was able, over the course of, I think, three years or so, to get 44 states to pass legislation to exempt visiting team physicians from state licensure requirements. That's an impressive achievement. And that's because of the team effort of people. Individually, we couldn't make that happen, but the Council of Delegates came together and as a team, made that happen. At my institution, the Sports Medicine Institute. So about, oh, about 15 years ago, my institution was going through a transition and I met with the athletic director and the dean, and they say, Chris, what should sports medicine be here at our place? And I'd put some thought into it. I remember telling him, at an institution as large as ours, and with the breadth of expertise that we have, we should not limit our sports medicine providers by housing them and keeping them restrained in their home departments. We need to take the orthopedist, the family medicine docs, the internal medicine docs, the PM&R docs, the exercise physiologist, the biomechanist, the athletic trainers, the physical therapist, the sports nutritionist, the sports psychologist, all these people that our institution were doing quote-unquote sports medicine, we need to bring them together under one umbrella, under one center. Well, they accepted that, we moved forward on it, we formed an organizational center, both on the academic side and the clinical care side. And I would describe what we have today now as a multidisciplinary, multi-mission integrated model. You can see all the different disciplines we have. When I had that discussion with the dean and the athletic director, and we started down that road, we had 12, maybe 15 people total in our sports medicine program. That includes the secretaries and the clerical staff. We're now well over 300. So proof is in the pudding. That model not only helped us have great success in recruiting and retaining faculty and staff and programmatic growth, we were also able to leverage that concept in some philanthropic success. We were able to build the Jameson Crane Sports Medicine Institute, 112,000 square foot sports medicine dedicated facility. I am convinced to my core that none of those things would have happened if we hadn't had the model of the multidisciplinary team working together. I'm not saying it was easy, but it led to some great success I'm very proud of. The Moon Group. I think everyone in this room is aware of the Moon Group. I was very fortunate to be a founding member of the Moon Group. You can see the different institutions and the faculty that were part of the Moon Group. Behind the scenes, sports staff, you can get a sense for how complex this was to make this all a high performing organization. But I think the Moon Group was a great example of how multi-center collaborations, multi-center teams can be very professionally rewarding. They can be very powerful. Here's the Moon Group winning the Kappa Delta Award. It can be very impactful. You can, all the peer reviewed publications that Moon generated. I know definitely for myself, and I suspect for most members of Moon, individually wouldn't be able to achieve those goals, but as a team, you can achieve big things. But it's not just on the professional side. It can be also personally very rewarding. You develop these lifelong friendships and very trusted colleagues. So when you're building a team, a couple comments, I think you need to beware of some traps. You need to be crystal clear on the objectives of your team. All right, by forcing yourself to be crystal clear on your objectives, that's gonna force you to determine and define a meaningful goal or research question for your team. And that will allow you to get buy-in from your team members, and that's critical to the success of your team, that your members all buy into and are committed to your team goal. And a clear objective will help drive the size and the processes of your team. Also beware, be very thoughtful of the size of your team, right, but be aware that increased size of your team also equals increased complexity of managing your team. If you're too small, you're gonna be ineffective, you could be underpowered. If you're too large, you can be ineffective and you can collapse under the weight of your complexity. And then don't be naive about the clash of personalities, cultures, and bureaucracies. You need to be very thoughtful of those as you put your team together, because if you don't pay attention to those issues, that makes maintaining your team even more difficult, and it's difficult enough if you don't take into consideration these issues. Now, if you're an Einstein, an Aristotle, or a Shakespeare, these guys achieve some great things on their own, you can, you know, go alone. But if you're like me and most of us, I recommend you find a team, one with common vision and values, teammates that you respect, and you value the same goals. Now, to me, a corollary of team is mentorship. I think any high-performing team, almost by definition, has significant mentorship going on. And a lot of the great mentors I know were big believers in teamwork and team concept. Now, I'd be remiss if I was discussing mentorship in a talk and I didn't recognize one of my mentors, Dr. John Bergfeld, who is a huge believer in working together as a team and teamwork. I also wanna touch base on Larry Senn. Larry Senn published, he has this book on the mood elevator, and you can see the different types of moods on the right there that you can have as you go through life. The ones on the bottom are negative, the ones on the top are more positive. And you can see at the very top of his list is being grateful. And he would say, and I agree with him, you can choose to a large extent what mood you're gonna have when you go through life. So let's be thankful. Even though medicine's becoming much more challenging, it's still a better job than 99% of the people in the world have. And we can never forget or take for granted our home team, right? This is your foundation, your home team. So in our sports medicine journey, let's be thankful. Let's embrace it, and I have three bits of advice. One, be very thoughtful and proactive to find your personal professional balance and do what you can to minimize those traps that we just talked about. Number two, don't go alone. Find a team. It's gonna be much more rewarding, but at the same time, not necessarily easy, and you have to be aware of the challenges. And number three, find a mentor and be a mentor. So last slide. Our sports medicine journey, it's a living, dynamic, evolving process. Let's enjoy the ride and remember, it's later than you think. Thank you.

non-opioid pain control

traditional opioids

shoulder surgery

side effects

osteoarthritis

rotator cuff repair

labral tears

cartilage defects

hip arthroscopy

femoroacetabular impingement

post-operative alpha angle

return to sport

collaborative efforts

work-life balance

fulfillment in work