to come up here and give a presentation on some of these issues. I think this is, we all have a lot to learn from it. Just general disclosures not relevant to the talk. So my case is shoulder and it's just a latter J. What could go wrong? I'm sure most of you think a latter J isn't always that easy anyway, but really thinking, if you've done this operation enough times, you'd think, well, got it down pretty well. But we're gonna talk about some of that, as Lynette said, that other side of taking care of the patients, not just the technical complications that are important. So this is a fairly severe issue with a, at this point, a 19-year-old with rather severe epilepsy, not controlled so well, despite a lot of meds. And so I had taken care of his other shoulder, stabilized it, and they never had a further problem with it, but he came for this shoulder. And starting out in January of 15, we did, he had seizure disorder, but he had anterior instability too as well as some posterior issues. And so ended up doing a posterior capsuloraphy and labral repairs, and he had a huge Hill Sachs. And so we bone grafted that, and it was like a, quite well bone grafted at that point. But three months later, he had a rather severe dislocation once again. And you can see now at Hill Sachs, the bone graft's completely compressed, like kind of destroyed. And we'll go through looking at what else he did. So I went back and ended up, so after this dislocation, now he had glenoid bone loss. If you look at the bottom, there's not a whole lot left on that glenoid. I mean, it's probably more than 25%. It's certainly, even on the order, getting up to 50% of glenoid bone loss, large Hill Sachs. And so we ended up going back and doing a revision. So with Laterge, capsuloraphy, suture anchors, where possible with that. And so I kept him at our ASC overnight. We have an overnight, or one where you could keep people overnight. We had talked with neurology ahead of time. They had increased his meds, which I think is a good idea. But 24 hours after this Laterge, he seized rather severe with meaning that they couldn't get it under control for hours, even in an ER. And so his head was just crushing against the screws. So even a one day out, he's broken the screws. And then you'll see with looking there with a CT, the coracoid, the Laterge is fractured in half, broken screw, big Hill Sachs again after fixing that. And so now what do we do? So this is now, he's had three operations on this and the parents, the patient, the parents are pretty distraught, feeling like despite talking with neurology, planning, doing everything, he still had a seizure rather immediately. And now the surgery has totally failed, even though we were sort of going into it, like we're finally gonna fix this, we're doing this Laterge, you should do pretty well and now it's failed. And I think like that creates a situation where now there's uncertainty with the family patient, whether we could really fix this completely and whether it would really stay, could we can, are the seizures gonna be controlled? They really have lost a bit of faith in the medical team. And it was very traumatic to break the seizure and then trying to get him relocated in the ER. So it's kind of a difficult experience. And so error and judgment, perhaps one. So in judgment, so in retrospect, this was a really, a fairly poor controlled seizure disorder just was hard for neurology to control that. Should we have admitted him for a few days on their service to keep this under better control? Probably so. But at that point, I didn't realize probably how severe that was, that would have been better than just an ASC overnight. So something to think about. And then in technique, which we'll talk about, but first of all, use of cannulated screws. I think in general, I've moved away from that, not even using cannulated screws on bone blocks anymore. Cause I think it's just at high risk. Most people that do enough of them will tell you that anyway, you probably should use solid screws or buttons or something else. And then using a coracoid for your bone block, any elatergy or something like that. I've also moved away from that in seizure patients. Cause if they do seize again and then they break their screws or break that or injure that bone block, then they don't have your short head of your biceps and then your coracoids gone if they do something. So I think someone like that, who's at potentially more risk to hurt that bone graft, you might be better off doing something else, which I've switched to just using distal tibia or something else instead of with a seizure patient using that. So I think Matt's talked about this, so I won't belabor it, but owning the complication. And so being clear with them, like saying, I probably should have used solid screws or maybe we should have admitted to them saying, yeah, I think there's something we could do better here. And also don't avoid, as Matt said, that sort of lean in concept. So I met them in the ER, obviously like at Duke, we have residents and people that would go see them. But when I heard what happened, I met them, they were really upset. And so we went over everything, patient was admitted, and I visited them in the hospital, making sure they knew what our options were. And instead of avoiding the situation, I think that's important to make sure that we have that trust. And something else I wanna mention we haven't talked about is let's say you wanna schedule another surgery and say, okay, guys, we have to revise this. Emphasizing that you wanna be there for the patient and wanna take care of the problem and that you're committed to seeing them through. But I think you need to acknowledge that the patient and family might be uncomfortable since the complication occurred and saying, maybe if you feel like you wanna get a second opinion or you'd like to see somebody else, that's okay because people do feel weird about saying something when they do feel that way. And what I do is I'd say, if you feel like you want a second opinion, I'm happy to help you set that up with somebody I think is really good. So like saying, I recognize that you might be uncomfortable continuing with me because something happened and let me help you, I'm not abandoning you, I wanna help you. And it's amazing how often people say like relief, like, yeah, I don't think so, I really wanna work with you or I wanna stay with you, but thank you for saying that because I was thinking about that, I don't know who to see. Every once in a while, they take me up on that and I make sure they see somebody that I think does a lot of that operation and is good and is gonna help them with that. And so I think that's really a good idea to acknowledge that uncomfortable thing. So here's what we had to do, of course, no good case is good without showing what you did. So unfortunately, bloody pictures, I wouldn't put that in the journal, but anyway, you can see the gigantic pill sacks, you can see like a large osteocondyl allograft with some screws there. And then the glenoid, if you guys can see what that is here, hopefully I could point to it, but you can probably see, I mean, like 50% of the glenoid was gone. So it's like a 50%. So distal tibia is the only way to fix that, a Latergé wouldn't have done anything and he needed the cartilage. So I think that's exactly what we needed to do for this particular kid. I also, of course, admitted to neurology and they kept him like five days to monitor and to really snow him. And for six months, they kept him on drugs so he could hardly keep his eyes open, but he didn't seize again and it healed. So that was good. Okay, so this is what it looked like. So now he's got a really large, like a glenoid surface area where it's pretty hard for that to jump out either direction, I thought. So you can see the Hill Sachs, I probably could have done a little bit better getting that more lateral, seems like that, but I think as long as, you know, I think it'll be hard for that to dislocate out the front, that Hill Sachs I think is well-protected now. And so the lessons are seizure control, maximize that, avoid Latergé or bone blot like that, because if it fails, you've really lost that anatomy for the patient and it's really hard to revise because your nerve isn't well-protected, it's a little nightmare to take that down, use solid screws, as we said, correct bone loss, don't do soft tissue procedures necessarily with seizure patients, think about the bone loss more with those, be really clear about the potential complications, make sure you're thinking about, you may have to come back and revise. And the end of the story is, he did well over the six months, he's not had another, like he didn't have another seizure over the next year with the change in meds, and I've followed the patient over several years to continue to make sure he's doing well because I fixed both shoulders and this family refers me all their friends and people, which I think is always like rewarding when you've had a complication like that because you appreciate the trust a little bit more. So if patients believe you didn't intend to cause them harm, you stay engaged and lean in, they're probably not gonna go elsewhere and they're certainly less likely to see you, which is not the reason to do any of this, but I think that's something to think about when you have a complication that being ahead of that and having them gain trust and stay involved and that's less likely to happen. So with that, I think I'll end here and if Chris is still working on that, Chris, you wanna see if we can get you lined up here? Yeah.

severe epilepsy

shoulder issues

multiple surgeries

complications

seizures