Good morning everybody. Thanks so much for being here. 7 a.m. second day, still going strong. Love it. So this morning we're gonna focus on, it's supposed to be a case-based roundtable discussion on the management of athletic shoulder injuries. So obviously we don't have the roundtables in here, but what we're gonna do is divide the group just into two groups. So you can kind of stay where you are, but when we have the discussion we're gonna have kind of one group on the right-hand side, one group to my left-hand side, and faculty if you guys wouldn't mind just dividing yourself between those two groups, and then we're gonna have the discussion within those groups. So the way it will be structured is we'll do two related talks, so two on shoulder instability, and then we'll have 10 minutes for discussion, and then we'll bring everybody back together just to kind of do a debrief for what you've discussed like in your two groups, and then we'll go on to the next two related cases, just so everybody knows what to expect. Okay, just trying to get this to cooperate. Here we go. Okay, so just wanted to do a quick introduction of our excellent faculty. So Dr. Brian Waterman from Wake Forest, Dr. Bert De Boer from Oslo University Hospital in Oslo, Norway, Dr. Sarah Edwards from UCSF, Dr. John Dickens from Duke, Dr. Greg Stanovich from the Ohio State. Filling in for Dr. Bishop, thank you so much for being here again, we really appreciate it. Dr. G Yagnik, I'm trying not to butcher G's name, from Baptist Health in South Florida, and Dr. Steve Brockmeyer from the University of Virginia. And then I'm actually just going to move into the first set of talks, so the first two we're going to focus on shoulder instability. So I'm going to give a talk on bank cart repair and a female collegiate soccer goalie with recurring instability, and then G is going to talk about a bony bank cart repair. These are my disclosures, none of which are directly relevant. So for this case, this was a 20-year-old right-hand dominant female soccer goalie who presented status post right shoulder dislocation while diving for a ball. The initial injury was three years ago, and that was reduced in the emergency room. Over the preceding three years, she didn't have any other gross instability events, but she had several episodes of shoulder subluxation. She had done physical therapy a few times off and on over that three-year period, and really didn't have any significant improvement in her symptoms. On exam, her range of motion was fairly normal. She did have a little bit of soreness at the extremes of motion. External rotation, internal rotation were normal, and then she had an obvious subluxation event with her shoulder and abduction and external rotation. These were her x-rays in clinic, so nothing too concerning there. And then let's see if I can get these to play here. Oh, I don't know what I just did, and we're not seeing anything. There we go. Okay, so I'm going to show you some related still images too, but I just wanted you to see a little bit of the video going through the MR arthrogram. Let's go back to this one as well, see if this one will play. So coronal, sagittal, overall looking okay. And then we'll go on to these still images, so representative coronal, and then two sagittal views. Rotator cuff looks fine, nothing significant on these few cuts. And then I'll show you the axial here. Oh goodness, let's go back. It's a little temperamental to get the video to play. So really her main issue, and as you can see on the single still image on the right-hand side, is she has a Bancart lesion, really no significant Hill Sachs lesion, and the glenoid overall in terms of bone loss looks fine. So these are some things to think about as we're thinking about options for her. So could we consider continued non-operative management in terms of physical therapy, activity modification? Yeah, well I guess, but she's a young collegiate soccer goalie, so really that's not reasonable at this point, given her recurrent subluxation. So then when we're talking about surgery, we can consider arthroscopic Bancart repair, open Bancart repair, an arthroscopic Bancart and a remplissage, or a latergé. So these are kind of the things we're considering. And then I'll dive in and show you guys some of her intraoperative pictures. So biceps superior librum looked fine, showing her posterior librum there on the right-hand side, that also looked fine, showing you a single view of her rotator cuff, which was intact. And then on the right, you can see really no significant Hill Sachs lesion. And then a few cuts of her repair, so bringing that freer in there, that easily went between the anterior librum and the glenoid. So I repaired this with three FibroTac suture anchors. You can use any company, but small. It's been great, obviously, to have access to these small all suture anchors, which don't take up very much space and allow you to place more anchors on that anterior face of the glenoid. Just showing there, as we get ready to place that third anchor. And then let's see, I think, there we go. So just a video here showing as we advance this. So this is a knotless mechanism. Probably many of you are familiar with this. This is what I tend to use for my labral repairs, and it works great. So you can either cut them as you move along, or you can leave the tail intact and then just tension it again after you've placed your subsequent anchors. So this is her final repair. And then on the right-hand side, just showing those sort of twin anterior cannulas. One just above the subscap, one above the biceps. You can also view from that portal, which gives you a great view down the anterior aspect of the glenoid. So post-op rehab. So I put her into a sling with an abduction pillow for four weeks. She started doing home exercises about a week after surgery. Formal physical therapy at four weeks. And the goal is to get her back to playing soccer in about four to five months. Now just briefly touching on a couple things from the literature. So here is this 2022 study looking at return to sport and outcomes overall following Bankart repair and soccer players. So the outcome scores improved. About 95% of the soccer players were able to return to sport at the same level. Mean time to return to sport was about 4.8 months. And overall recurrence was about 5%. So what the main take home from this is most soccer players who undergo Bankart repair are able to return to sport at the same level, and there's a low rate of recurrence. We do have to, however, take into account the soccer players position. Because we know that makes a huge difference in all the sports that we cover. So in this particular study, they had 70 position players and 11 goalkeepers. The post-op functional outcome scores improved significantly in both groups, but position players achieved significantly greater pre to post-op improvement. All players returned to soccer. About 55% of goalkeepers returned to the same level of play versus 93% of the field players. And the rate of recurrent instability was significantly higher in goalkeepers. And of course we understand that's an inherent to what the goalies have to do is are constantly landing on their shoulder. So overall the results of arthroscopic Bankart repair are favorable in all soccer players, but goalkeepers have significantly worse functional outcomes and a lower rate of return to sport, as well as a higher recurrence rate. So certainly this is information we need to keep in mind and use to counsel our athletes in general, and specifically this goalie. So as we move into the discussion after Gee's talk, some things to think about for that discussion is, you know, should we have special consideration in soccer goalies when we're thinking about arthroscopic Bankart versus a arthroscopic Bankart or REMPLIS-R's open Bankart, a bony procedure including Latter Jay? And is there anything different that we should do in our post-op rehab protocol or overall return to sport? So thank you so much for your attention and I'll invite Gee up here to give his talk. All right, so we're going to talk about a case with a bony Bankart, and I think it'll be a nice contrast here. We can see, talk about different options. So to catch up? Got it. I'm not able to advance it. Do you know if, did it test it out? Yeah, it tried it. So that should fit. It does. It honestly takes like a minute. There we go. What'd you do? So you like click on the slide and just play around. OK, we'll figure it out. So these are my disclosures. Also, not super relevant to this talk. So this is a case. It's a 17-year-old right-hand dominant high school football player. So he suffered a left shoulder injury about six weeks ago while he was playing in the game. He's a wide receiver, defensive back. So position, I think, is important. He reports a traumatic dislocation that he was able to self-reduce. He's a tough kid, so he finishes out the season. He comes in to see me after the season. He states that his shoulder still feels loose and that he maybe had felt it slide in the past. So this may not be a first-time event. So on exam, he's got fairly good passive motion. He's got pain with active elevation greater than 90 degrees. He's got a positive answer load and shift test, positive apprehension, relocation. So pretty classic exam for instability. So his radiographs look pretty normal, except when you look at the axillary, you can see this little fleck of bone here off the anterior glenoid. So it makes you a little bit more concerned. So if you look through his MRI scan, so I'll scroll through. There we go. So just kind of scroll through some of the axial cuts. And the coronal cut. So his cuff's intact. He's got that abnormality at the anterior ferroglenoid. No effusion, right? So this is not brand new. So some still shots here on the saggles. You can see this fragment of bone here at the anterior ferroglenoid. So what is that? What would you estimate that? 15%, 25%, 20%? Who knows, right? So coronal views, again, showing a cuff. So we got a 17-year-old football player with a bony band cart and a Hillsacks lesion. So I think some of the questions will be interesting for us to discuss is, is this a new or an old injury? Does it even matter, right? Is that something that comes into play? What about additional imaging? Mary showed an arthrogram. Should I have gotten an arthrogram? What about a CT scan? What are the benefits there? Your initial thoughts on management? Is this an operative case? Is this non-operative? Is there any role for non-operative care here? What about time of season? How does that influence your decision? Also, what about level of play? If this is a pro guy and it's October, are we having a different conversation than we are with a high school kid at the end of the season? So I think all these things are really, really important. We try to look at instability and try to make it very black and white. And it's really, really great. Same thing with your surgical options. Mary touched on these earlier, too. So what can you do for this kid, right? Arthroscopic bony band cart's an option. I know some people that excise this fragment and fix the soft tissues. It's reasonable. What about going open? What about a bone block? What about remplissage? Yes or no? Why or why not? How do you decide? So these, I think, are all important questions, things that we can talk about. So looking at the diagnostic arthroscopy, some kind of views from there. This is from the lateral position, looking from the posterior portal anteriorly. I'll scope all of these, because I want to see what it looks like. So I want to see what this bone fragment looks like, what the surrounding tissue looks like. And this was healed about a centimeter medial, and that's why he was recurrently unstable. So we kind of elevate this piece. And as you start to clear off this bone fragment, I mean, to me, this looks like not a huge piece of bone. I think that bone looks fairly healthy, and the surrounding soft tissues look pretty healthy. So do these intraoperative images change your surgical plan? Do you scope these before? Does everyone do it? I think this is something to talk about. Would it influence your decision making? I think sometimes it does influence my decision making if the soft tissues are not very good. So I decided to perform an arthroscopic bony back heart repair. I thought the tissues were good. I used this double row bridge technique that Dr. Millett first published on in 2009. It's basically anchors on the medial glenoid neck, bring the sutures over, and kind of surclodge that piece in the knotless anchors on the face. So I think it's important to really kind of clean off the glenoid neck there, so you get nice exposed bone for bone to bone healing. So this is viewing from the answer portal. I think the hardest part of these procedures is getting your passing suture or your shuttle suture around this piece of bone. It's a little bit hard with your traditional 45 or 60 degree lasso. So I think this crescent shaped lasso that lets you kind of put a bunch of PDS and scroll it all the way into the joint lets you get around this bone fragment. So this is what it looks like after your passing sutures around that bone fragment. You can see it's all the way around. That's what you're looking for. And then you go ahead and put your anchors on the neck. So one inferiorly and one superiorly. I use soft anchors here. I think they grab a little bit better, but you can use whatever anchors you like. And then this is what it looks like after you use those shuttle sutures to pass those sutures around that piece of bone. So we have two anchors. We have all the sutures now passed around that bone fragment. And then you go ahead and put some knotless anchors onto the face. So you take one suture from the inferior anchor, one from the superior anchor, kind of crisscross, put them into a knotless anchor that you then put on the face. And so this is the first anchor around the 5 o'clock position. It's a little bit of a struggle. You've got to kind of shift the head out of your way, and you've got to find your hole. So it's not the easiest case. And then you go ahead and finish off this anchor. And then you put your second anchor in. And so this is what it looks like viewing from the posterior portal. You can see we got pretty nice re-approximation of that whole capsule labral complex with that bone compressed, and then viewing from the anterior portal. So I think some questions we can talk about. What's your post-op protocol for this? What's your post-op protocol for this? And then we'll go ahead and move on to the next slide. Is it going to be different from your soft tissue Bankart? What about return to play timeline? What are you giving? Are you going longer with these patients? What about post-op imaging? Some people will get radiographs or CT scan to evaluate the healing. Is that a reasonable thing to do? And when they go back to play, are you putting them in a brace or not? So these, I think, are all important questions, good things to talk about. There's not a ton out there on arthroscopic bony Bankart repair. This systematic review, AJSM 2022, kind of summarized everything. They looked at 21 studies, 769 patients, mean age is young, and as you would expect, 42 months. They're mostly level 3 and level 4 studies, so 95% were that. And they included all techniques, so single row, double row techniques, anything that kind of fixed a bony Bankart arthroscopically. And overall, the results were good, right? So improvement in the PROs, I think a fairly acceptable recurrence rate, around 12%, and a high return to sport rate. So their conclusion was that this type of repair resulted in improved functional outcomes, low recurrence rate, and high return to sport. So I think we have some nice stuff to talk about. I don't usually put personal pictures, but Stanley Cup, and it's two weeks ago. All right, guys. So we are going to just kind of divide all of you guys into two groups. So one group, if you wouldn't mind kind of clustering over here, one group here, and then faculty, just divide yourselves up. We're going to spend about 10 minutes just talking about these two cases, and really anything you want related to shoulder instability, bony Bankart lesions, et cetera. And then we'll regroup just after that to kind of talk about some of the key points that you take away from the discussion. So go ahead, please divide up. Thank you so much. All right, guys, great discussion between the two groups. I think we're going to be just wrapping that up so that we can have a little bit of time to debrief, guys, if we can just kind of come back together. Appreciate it. And then we're going to take a couple minutes to hear what you discussed in your different groups before we transition to the next topic. So let's start with Sarah and Steve Brockmeyer's group and over here. Hey, guys, over here. We're going to come back together. So Sarah or Steve or G, do you guys want to share some of the things that you discussed in your group? It's at the bottom, I think. Yes. OK, great. Our group, we had a nice discussion about the bony bank cart and how we treat it. We heard in Norway she's using the arthroscopic Latter-Jay technique to put buttons and fix it that way, which is interesting because I haven't seen that yet. But I think that's a great way that I would consider using, too. And we talked about tips and tricks to kind of lasso that fragment in. Perfect. And then Steve discussed maybe doing a Latter-Jay. Any other tricks that you guys discussed specifically in terms of actually passing, like being able to pass through or around that bony fragment? Yeah, so we discussed that surgery is actually complicated and G made it look really easy. But placing the anchors medially in cancellous bones, sometimes hard. Passing the sutures around, sometimes you can use kind of instruments or two different portals to kind of really visualize and get it passed. And then we talked about how the piece, Bertha pointed out that a lot of times when you try to tension the way that G fixed it, the piece will want to actually invert. And so sometimes it doesn't come back fully anatomically. One other thing I think that's helped, I'll reduce the fragment sometimes. You can preliminary fix it with, or put some anchors into the glenoid and then pass a straight lasso through the fragment. So instead of trying to surcollage the entire fragment, go through it. Awesome, thank you guys. All right, so for our group over here, John, do you want to share? Yeah, so I think it's on. So we had a good discussion. I think we first started off with just, we had a little bit of discussion about imaging and when we would evaluate with additional imaging that was brought up. I think there was some discussion about maybe getting a CT scan for some of the larger ones, maybe a little bit larger than this one, I think would be a fair statement from a consensus for our group. But especially as those, at least we were talking about the medial ones and understanding some of the larger bone block or bony Bankart fractures to see how they are, what their size is. We talked about adding, maybe being, using the remplissage kind of relatively frequently with instability, especially in the contact athlete. And we talked about timing, in particular with bony Bankarts and wanting to get to these earlier rather than later. And maybe that's a discussion with an in-season athlete and maybe in a shared decision-making model, kind of trying to at least kind of weigh the information that's at hand with that athlete that's in-season, if that's the case. And then we had a discussion about if this was a chronic bony Bankart that wasn't well healed, or was well healed but medial and not mobile, moving to bone augmentation type procedures, such as a LatterJay. So there was a good discussion there. I think Greg at his institution, interestingly, the culture is you find people at Ohio State that want the bony procedure on the football team. And so they're very comfortable with that. So that was good. And you had some people who were worried about LatterJays and contact athletes. That was a good discussion point, I think, as well. Awesome. Thank you guys so much. All right, we're going to transition to the next section, which we're going to focus on biceps and slap pathology. So first up will be Greg Satanovich from the Ohio State talking about biceps tenodesis versus slap repair for a slap tear in an overhead athlete. And following that, Dr. Sarah Edwards will talk about acute subscap tear and associated biceps instability. All right. Thank you very much. And I just wanted to note that I'm filling in for my colleague, Dr. Bishop, who couldn't be here today, unfortunately. So I wanted to give her credit, as most of the slides are hers for this last minute switch. So here's disclosures. The case here is a 27-year-old female volleyball player with a slap tear. Patient has a history of playing high-level club, former collegiate player, also avid working out at the gym. Presented to the office with six months of gradual onset shoulder pain, really no acute injury, just been playing a lot of volleyball. It was a nice, warm summer. Pain is worse with overhead serving, blocking, and really any overhead activities. No impact of sleep, no impact with other lower activities. It's really the overhead with force and resistance like hitting the ball. And has tried NSAIDs, kind of reduced workouts, dropped the weights a little bit. Still having pain, mainly kind of an anterior pain is the presenting location. And came in with an MRI, told she has a slap tear and needs it fixed. So first thing you want to do, of course, is a physical examination. And luckily, there was normal appearance to the shoulder. She had some mild tenderness anteriorly over the biceps groove. And that was kind of where she localized more of the pain. There was maybe a milder posterior pain. Good range of motion, a little bit of asymmetry of the scapula on the right with range of motion. And so some mild scapular dyskinesis here. Strength intact, negative testing for instability, positive testing for Speed's test, O'Brien's test, reproducing her pain. I also do a labral shearing type exam maneuver. And that would probably be painful for her as well. Of course, she had radiographs, which were normal. And came in with this non-arthrogram MRI. So one question could be, what is the role for an arthrogram versus a non-arthrogram MRI? Arthrogram, probably slightly higher sensitivity and specificity. But does that work against you in the case of slap tears, perhaps? Maybe you're just picking up too many small ones. Might be a consideration. For me, I usually will go with the plain MRI. I think that lets you see what you need to see for the majority of these. And so she has this type 2 appearing slap tear on the MRI here. And so we had to talk about that. Of course, very important to educate the patient. And asymptomatic slap tears are very common. So this patient's symptoms going on for six months may or may not be related to the time course of developing the slap tear. This could have been there since playing volleyball in college and not bothered her until recently. And so in MLB pitchers, half of them have a slap lesion. In volleyball, probably it's similar. So is this a physiologic adaptation? Do we need to be fixing all of these? And if we repair these, is this non-anatomic? Is this going to work for them? Or is this going to give them other troubles? So for slap tears, I start by telling them this is something that you can live with. You may have had this for a while. It's usually not a traumatic injury, with some exceptions. And we start by shutting them down somewhat from overhead sports, physical therapy, trying PT, generally for a few months. Although if it's working really poorly, we'll accelerate interventions a little faster than that, perhaps. This patient had some improvement. The scapula was looking better six weeks later, but still having pain. Tried to go play volleyball, couldn't serve. It was painful. And she doesn't want to live with this. It's not impacting her work, but she can't do the things she loves to do. So for me, you can discuss going to surgery. It's a little bit soon for that, with just six weeks of conservative treatment. So often, an intermediate step could be an ultrasound guided injection. Personally, I do a glenohumeral injection. Although if I felt like the biceps was a dramatic pain generator, you could go directly for a biceps injection. But I think the glenohumeral injection will get down that bicep sheath for the majority of these. And this was very effective. So it gives you some diagnostic information that the pain is coming from the biceps, or the bicep supralabral complex. And sometimes this can be a huge game changer for people. So for her, it was, but only for three months. And then she comes back. And generally not going to repeat injections and tell people this is more of a one-time thing, unless they come back years later. And so for her, she wanted a definitive surgical fix for this. So for Julie in 2007, which was before I was in practice, this is what she would do. So she would do a scope and look at that beat up superior labrum, and then fix it. And it appears to be before knotless anchors at that time. So I think there's been some evolution in that way that could be helpful. I think these knots up in that location cause a lot of irritation. I think that the knotless techniques would be superior. However, in 2024, Julie and I agree, I don't think this is the way that we would go for this patient. So the slap repair outcomes historically have not been great. Low rates of return to play, low rates of satisfaction, and relatively high failure and revision rates that are generally unacceptable in these high level patients. Also mirrored by studies in the military, which has shown higher failure rates with the slap tears. Certainly there's complications. Some of these are solved by more modern knotless anchors, irritation of those. But generally patients will get some stiffness from this, especially if you go anterior to the biceps. And residual biceps pain I found to be a major problem with these patients. And so many studies and research has looked at slap repair versus tenodesis. And a lot of literature supporting higher satisfaction rate for the tenodesis patients. And return to play trending towards higher, although overhead athlete return to play after shoulder surgery is always somewhat iffy. And so what I would do for this patient would be an arthroscopy, evaluating and debriding the labrum. I would almost never repair it for this unless there was a paralabral cyst or a very unstable flap. But I might just debride that anyway. And then I would be doing an open tenodesis. Certainly there's many ways to do a biceps tenodesis and we can discuss that in our groups. For me, I think it's a balance of treating the pathology while avoiding complications, and so that's how I like to think about it. And SubPEC, I feel like, is more definitive. It takes just a little bit more time than arthroscopic, but not much, and avoids the possibility of residual anterior pain. And for me, very important to keep the length-tension relationship, and I use a unicortical button or a unicortical all-suture anchor to avoid the large stress riser in the tunnel there. And have little to no stress fracture risk for these overhead athletes or high-level patients. And so, this is a video. It's all together, this is Julie's video. It's too long for this setting, and I don't know how to skip ahead. So she does a little more of an open approach than I do. Mine's a smaller incision, a little more of a blind dissection. I think we can talk about pros and cons of that, but does a good job here of identifying, I don't know how to skip the video. Identifying the, advanced, okay. Identifying the muscle-tendon junction here to get the length-tension relationship, and then drills and inserts the button. Post-operatively, we put our patients in a sling for a couple weeks, try to avoid eccentric biceps firing. Six to 12 weeks, working on range of motion strengthening, working on the scapula as well, and then return to sports, generally around four months, maybe up to six months, depending on the activity. Thanks a lot. All right, good morning. Thanks for being here, everyone. My name's Sarah Edwards. I'm gonna talk to you today about subscap tears and bicep-tendon pathology in athletes, which is a very rare problem that we see. Those are my disclosures. So subscap tears, you know, in the general population, it's about three, three to 4% of all rotator cuff tears. Partial thickness tears a little bit higher, about 20%. In athletes, it's even more rare. So it is a potentially debilitating injury when they have a full thickness tear. Most frequent are traumatic tendon avulsion tears. But in the older population, older to elderly, you might see this chronic degenerative process that precedes a sports-related trauma. So something to think about. Clinical implications range from diminished athletic performance to serious disability when they rupture. We know subscap's the largest, most powerful rotator cuff muscle. The upper two-thirds inserts on the lesser tuberosity, that's the tendinous part. What I always really put across to my residents, particularly when we're doing total shoulders, I do a lot of shoulder arthroplasty as well, is that that lower third is very muscular in nature. So I use different suture to repair it when I'm coming out. And it inserts all the way down on the humerus. So it's a large, flat muscle, something to think about when you're doing the repair. A common insertion of the coracohumeral ligament and superior glenohumeral ligaments is on the lesser tuberosity. It forms the reflection pulley. It stabilizes the long head of the bicep before it enters the groove. So that's why the two go together. We know that acute high-energy sports is the most common mechanism of subscap tears in athletes. Golf is actually the number one thing that you'll see. We use our subscap the most when we're playing golf, with a forceful internal rotation. But in the trauma, you might see it in water skiing, baseball, and arm wrestling. Typical mechanism is violent hyperextension or combined adduction and external rotation maneuver. I can say it's exceedingly rare. I've been in practice 20 years. I think I've fixed two in 20 years. Anyone else have any thoughts on that? Mary, how many have you seen? Zero, right, to date. Two, exactly. Steve, how many, did Steve leave? Steve peaced out. Anyway, but yeah, very, very rare. I'm sure he'll be back. Anyway, so in older athletes, the tendon usually ruptures first. So anyway, so this chronic overused microtrauma can precede it. So something to think about, coracoid impingement. You also might need to address the coracoid when you're doing this. Other sports, again, we talked about golf, tennis, and then butterfly swimmers. Again, that's a big one I see in California, the butterflies. The isolated subscap tears in athletes. Again, the true incidence is not really known. How do they present? So most patients will report acute trauma, forcible hyperextension, and external rotation. On physical exam, they'll present with tenderness over their lesser tuberosity. They'll often have, if they have a full thickness tear, you might see increased passive external rotation. They can have diminished internal rotation strength, and then the common test that we know, the bear hug sign, belly press, lift off, can all be positive, all things to look for. And then their bicep tendon signs, such as the speeds test, will also often be positive. So, again, this is something, if they have a full subscap tear, something you wanna fix relatively quickly due to the incidence of retraction. It can scar down immediately, and then it becomes very hard to fix arthroscopically. If they're partial tears, often you can debris them. Again, we use the 50% rule. You wanna fix it if it's over 50%. And then, again, addressing the bicep tendon subluxation, something to look for. And then, again, the corcoplasty, if you need to, you can evaluate and see if they have that coracoid impingement on their preoperative imaging. So, you can do these open or arthroscopic. So, it's interesting, in baseball pitchers, they'll often rupture the lower third. That muscular part is more vulnerable. So, that's someone, if it's a lower third rupture, that's someone I would recommend doing open. If it's a tenderness upper part, those are ones I would do arthroscopically. The largest case series to date in the orthopedic literature is 13 patients. This is how rare it is. Open repair was used for isolated subscap tear. They didn't open. 12 out of 13 were able to return to their pre-injury sports activity level. So, again, tips and pearls when you're doing this. Be prepared. Look at the axial cuts yourself. So, sometimes when you go in, I find that radiologists often miss this. So, I think it's important to look at your MRI reads yourself and look at the subscap. They'll get excited, particularly if you're doing an older patient. Maybe they have a super tear as well. They can miss the subscap tear. Look at the bicep. Anyone who is read as a subscap, or I'm sorry, a bicep dislocation, look at their subscap, because often you'll find some pathology there. Tips and pearls, when I fix these, use a traction stitch to assess mobility of this tendon. Use cautery, anterior and posterior to the subscap to mobilize it. Some people suggest a 70 degree scope. We can talk about that. I use a 30 degree. I usually use one anterior cannula. I will deal with the bicep first. So, I do the subpec bicep tenodesis as just described. That's how I would address that. I get it out of the way initially. And then I like to use suture tape, pass it in a mattress-like fashion, and then one self-punching lateral row anchor to tag that down. And then I take the arm through a range of motion to make sure it's complete. Again, this is just some pictures looking at the subscap. That's me doing a bicep tenodesis. I like to use a meniscal biter after I tag it with PDS. I think a biter's a nice tool to get rid of it without worrying about cautery. At this point, I would expose the coracoid and do a coracoplasty if necessary. Coracoplasty's pretty easy arthroscopically. So, for those of you who haven't done it, it's actually quite easy. It's sitting right there in front in your interval. So, you just open up that capsule in the interval and you see it. You can assess your tear, debride it, do a side-to-side repair or anchor if necessary and looking at the different type of tear pattern. And then this is passing a mattress suture within the subscap. I use the Scorpion Passer device, the self-capture one, which is nice, and just invert it so the mattress, the sutures are coming out anteriorly and you can pass that suture quite readily. And then you can put traction sutures in if necessary to gain additional function. And, hang on, I'm just clicking through. It's trying to do video. And then again, I put that anchor into the lesser tuberosity and you can tap for it or I, now there's so many nice self-punching anchors that I don't think you necessarily need to do that. If you're just doing an intersubstance repair, you can shuttle sutures easily using suture passers to close that interval down. And again, those are the anchors that I like to use. And those are, again, different techniques for the intersubstance. You can shuttle the sutures and do them side-to-side. Partial tears, again, depending on where it's torn, I'll often try to anchor it to an anchor on the lesser. And then at the end, assess the subscap repair, take the arm through a range of motion and make sure it's really fixed down. So again, in conclusion, acute complete subscap tears are very rare in athletes. Look for them inferiorly. If that's the case, particularly in a thrower, I would suggest doing it open. Partial subscap tears are a bit more common, particularly in the aging athlete. Be prepared when you're going in to address pathology, particularly if they've got bicep tendon subluxation. The subscap's often gonna be torn as well. And then be prepared to address the coracoid. Overall, the results are good. So, thank you. We can talk about different techniques or pearls that you all have. All right, we're gonna break up again into the two groups, guys, and then we'll have a little bit less time for this just to make sure we can still keep moving forward, but please just divide up as you were if you don't mind. All right, we're gonna bring everybody back together again. Again, a little bit shorter time for this discussion, sorry. If you guys wouldn't mind. All right, sorry, I know, it goes so fast, right? So, we'll start, let's start with John's group over here. Oh, yeah, or Greg, it's at the bottom of it, yep. Yeah, so, great discussion over here. We talked about the slap tears and discussed the most problematic, which is the high-level pitcher with a slap tear, which is the one we still don't necessarily know what to do and so, definitely best option is not doing surgery, but if you have to, then a fairly limited slap repair, probably still appropriate in that group, although consideration for biceps tenodesis depending on the pattern of the tear. And then we talked about subscaps briefly. We didn't get into it too much, but discussing the importance of managing the biceps tendon in the setting of subscap and then literature suggesting that some of the limited upper portion subscap tears may not need to be repaired, especially in older patients. So, I think that's a point of controversy, but we discussed that one. Great, thanks, Greg. All right, for our group over here, G. It's at the bottom, sorry. So, I'll keep it real brief just so we can get to these other cases. We really didn't touch on subscap. We talked mostly about biceps tenodesis, above the groove, below the groove. I think there's a little controversy there. So, trying to get a little bit of gestalt as to what people do. And then we talked very briefly about, what was the other thing we talked about? That was mainly it. So, I'll let you get back to the. Awesome, thank you. So, what we're gonna do, we have four cases left. We're just gonna actually go through the four cases and then use the remaining time for discussion. So, the next two cases are gonna be related to the cuff, and then we're gonna transition to AC and SC joint cases. So, in this next section, we'll have Dr. Brian Waterman talking about a traumatic cuff tear, and then Dr. John Dickens, partial rotator cuff tear in a throwing athlete. After the two cuff cases, we'll have Dr. Bertha Burr talking about acute type three AC separation with horizontal instability, and Dr. Steve Brockmeyer, posterior SC joint dislocation in a football player. Thank you. Thank you. I can't wait to see the SC joint dislocation. That's always exciting. All right, this is a little bit of a unicorn, but the primary rotator cuff repair in a high-level athlete for a full thickness tear, my disclosures can be found online. I don't think there's a ton that's really relevant to the content of this case, but it's kind of a nontraditional athlete. This is a 39-year-old jiu-jitsu instructor. He owns a shop in town, and he's very involved with competition as well as instruction, and this is his livelihood. And so, much like many of our MMA athletes, he's got some chronic shoulder pain, and he has an acute event during a painful takedown. It's been refracted to conservative measures. He does have night pain. And I'll paint a picture for you, kind of as a rock-esque kind of appearance without as many of the tribal tattoos or veins, but he's equally intimidating as he comes into my office, takes off his shirt, and we get this exam showing full range of motion, painful arc, positive provocative bicep symptoms, and cuff weakness. Much like many of the individuals we see, you can see some degree of greater tuberosity remodeling. You know, the significance of this is indeterminate, and there's a little bit of subchondral sclerosis on the undersurface of the acromion, but not much there, really a fairly normal appearing shoulder. Sorry for the coronals getting a little bit cut off, but you can see there's definitely some vertical instability there. There's a cuff tear involving the supraspinatus and infraspinatus. There's some degree of fatty atrophy on that sagittal image. And then, much like Sarah had mentioned, there's bicipital pathology and suggestion of a subscapularis tear. We talked a little bit about this in the last section, but that posterior lever push is really nice for identifying those tears that may be a little bit hidden, and you can see that bicipital instability. Our solution for that is to cut the biceps. You certainly could incorporate that into your repair as an anterior cable reconstruction for an older individual, but in this case, this is one where I preferentially would use that for tissue augmentation. I like the superpectral technique. You can localize this with an adjunctive portal. You can decompress the groove, and then subsequently go ahead and use a single all suture anchor, preserve that two and a half centimeters, and then use that potentially for a bicep smash technique. I won't belabor this point, but doing a three-sided release for the subscapularis is key, and so I like to get this traction suture in the comma tissue to excoriate the undersurface of the coracoid and really do this coracohumeral release in continuity to make sure I get a nice anatomic repair, because I think that's the keystone for the remainder of my cuff tissue. So it starts with the force couple, subscapularis, then to infraspinatus, and then finishing it up with supraspinatus. I like an onlay for this proximal third type tear. You can see we just get these cinch sutures in and are able to restore that quite nicely. Then it's going in the subacromial space, and I really would put a plug in for lateral viewing. I think that that is key. When you look at these L or reverse L-shaped patterns, it's sometimes difficult to appreciate from the posterior portal, so make sure you're restoring that normal anatomy. And that's shown here. You can see we're viewing. Sorry for the multitasking, but tight timeline. You can see we're gonna prepare the footprint, make sure we have a full view of the subacromial space, and you can see we've got this reverse L-shaped tear with the lamination while viewing from the lateral portal. So we're gonna go ahead and attack that, and I'm a big fan of margin convergence and traction sutures. I think that just allows me to simplify the repair construct. And so you can see we're gonna get these sutures on either side. I'm gonna take that posterior delaminated segment in two bites. You can do that with a tissue-piercing device, or you can use suture hooks, whatever your preference is. But what we know is that that will help to decrease our strain, our gap formation, and it'll allow for a greater surface area available for repair. And that's shown here in this elegant Gup Smizaka study. Again, here's us tying those margin convergence. You can see we're just gonna get right over the top there, and you can see as we get that down, it's really gonna restore nicely that tissue. Because a lot of these athletes, a lot of these folks that have some element of calcific tendinopathy, or like John's gonna talk about in a couple minutes, that partial cuff tear that subsequently completes, they really have a lot of diseased tissue. And so it's incumbent on us to make sure that we're getting that back in a tension-free repair. So then we do a suture-anchor-based side-to-side margin convergence, add an additional anchor anteriorly. What I love about treating cuff pathology is really it's DIY. Every time, you're doing a different kind of construct. And so I'm trying to preserve the footprint because I'd like to do something for augmentation. So we use a couple of these cinch sutures to bring forward that dog ear, and you can see we've got a nice double-row construct shown here. These self-grasping sutures, I think, are very key. They help to prevent tissue cutout and augment the strength of your repair. In terms of tissue augmentation, we've alluded to some of this, and hopefully this'll be a source of discussion as we break out. But you can use autogenous biceps using the biceps-smashing techniques that's been popularized by J.T. Tokish. Again, you need about 2 1⁄2 centimeters in order to generate this nice live tissue augment that you can re-approximate with whatever technique that you prefer. And then in this case, we also could consider a dermal augmentation, which is a structural augment. You can use these meniscal-type fixator devices in order to reinforce that tissue. And again, that's a great tool to have in your tool chest. I don't think you have to worry about overstuffing, and the technical aspects are fairly easy. So again, an intimidating jiu-jitsu instructor. You can see here he is in follow-up. He's got excellent range of motion, and I think a very functional endpoint. He was able to resume competition in around five or six months. As you consider optimizing all these factors, I just would encourage you to try to look at each individual one of these and try to figure out how you can best achieve your end goal because I think each patient requires an individualized plan. Thank you, and I think I'll pass it off to John. Thanks. Thank you. All right, I'm going to talk about partial thickness tears. And this is a case, it's the closest thing I have to a thrower recently here. So actually a football player, lineman. He has a junior. He's had a prior subluxation event on this right shoulder previously, but was treated non-operatively and no recurrent instability events or symptoms from that. But then has subsequently started to develop pain, particularly laterally-based subacromial type pain symptoms with overhead lifting, as well as some of the throwing stuff he has to do. We're in the off-season. He's like anybody that plays football, is hopeful to play in the NFL. He's really limited with overhead lifting, and that's kind of his biggest complaint and what's limiting him the most. And he's not able to perform, and it's taken away from his ability to develop from a football standpoint. He's got some impingement signs. He's painful but strong with rotator cuff testing in the supraspinatus. No biceps symptoms and no instability symptoms. And the x-rays here for the purposes of this are normal. And then let's see if these will play. So these are our images. And I think subscapularis and biceps are looking OK. I think on the coronal image, you can see some of that partial thickness rotator cuff tearing, especially here. So here's just a little bit more of a still shot of that. So he's got a anterior supraspinatus partial articular tear, as well as really more of an interstitial tear. And so a number of different ways that we might think about options for this person Is there a role for PT versus surgery? I'll tell you that he's had a kind of an extensive non-operative course. Is there a role for injections or biologics? And then, as Brian has talked about, the surgical options. And if you're going to do that, what are the surgical options? And maybe something we can consider in our discussion that might be kind of a pasta repair, a takedown, an augment, on-lay type graft. There are certainly a number of different just considerations in the partial articular rotator cuff tears that we should know about. And I think, first of all, for the young athlete, these are generally symptomatic many of the times. For the over 40 patient, of course, many of those are asymptomatic. So I do think that it is a little bit more likely to present if they do have that in the younger patient population. There's been some discussion about the critical shoulder angle and what that means, and the lateral acromion with an angle of 35 degrees being a little bit more likely associated with rotator cuff tears, and lesser degrees, less than 30, associated with instability, and then if it's prolonged, rotator cuff arthritis. And then what about the likelihood of these tears progressing? In partial thickness rotator cuff tears, what is the chance that they do go on to progress to a full thickness tear, like we were discussing? Because that's really the important question here. Ian Lowe did a good retrospective study. 76% of these partial thickness rotator cuff tears of all comers over two years did not progress. So that's good information, and one of the criteria, obviously, is the size of that rotator cuff. So if it was less than 50%, only 14% of those tears progressed, but if it's greater than 50% thickness, then they had a 50-50 chance of progression and failure. There's been some work by Steve, as well as others, that are here regarding injections and the role of corticosteroid injections for athletes, particularly with partial thickness rotator cuff tears, and how that might influence decision making, so rotator cuff tears, maybe considering an injection, corticosteroid injection is something you might do, but if surgery is in the future, I think it's important to know that within one month, a higher risk of infection, and maybe even that's up to three months after or before surgery, and then within one year of injection, increased risk of re-tear and failure of a rotator cuff repair. And then what about biologics? So there's a couple of options here. You can use PRP, as well as comparing that to corticosteroid, there's a few actually good randomized controlled trials that are out there. This one, again, from Ian Lowe's group, in a partial thickness rotator cuff tear patient population, PRP was superior to corticosteroid at three months, but at 12 months, no difference in their patient reported outcomes. And then this study from the American College of Sports Medicine is another randomized controlled trial, and this is a randomized controlled trial between saline injection, PRP, and PRP versus HA as a subacromial injection for these partial thickness rotator cuff tears. The take-home point is that any PRP injection formulation, whether it's with HA or without HA, was superior than corticosteroid. So they actually compared, or followed these up at one year with MRI, and so not only patient reported outcomes, but actually MRI evidence of healing, and this was even superior in the HA PRP group, more so than the PRP group, but both superior than compared to the corticosteroid. So this was actually, what we ended up doing is just, I chose this just because you can see some of the follow-up imaging here, and this is on the left, that original image, and then he ended up, 18 months later, with repeat imaging, and you can see some interval kind of change there in his supraspinatus. So that's our partial thickness cuff tear. Thank you for inviting me, Murray. It's a pleasure to be here, and there's thousand things to discuss about AC joint injuries. So you asked me for a type three horizontal, but we are not very good in doing this classification, so we'll see what you get. Okay, trying to get the slides to, yep. I have some disclosures, most of them scientifically. This slide just to remind you about some of the anatomy around the AC joint. When we do surgery for these patients, we have to know the distance from the joint to the CC ligaments. We have two ligaments, conoid, approximately 35 millimeters from the joint, and trapezoid, two and a half centimeter from the joint. And we all know that when we do surgery, most surgeons will replace these two ligaments with just one suspensory device, or maybe one tendon if it's a chronical case. So is that really an anatomic reconstruction? For the biomechanics, to have a normal range of motion, we need some movement in this joint. So we cannot make a reconstruction that is too stiff. So normally, we would have approximately five millimeters movement, both anterior, posterior, and superior. And also, a rotation of 45 degrees is necessary to do a full abduction of the arm. So making a reconstruction that is too stiff will limit the range of motion of the patients. We did some epidemiology in Oslo a few years ago, showing that the AC joint injuries are men in their 20s. So, and also, more than half of them were coming from sports-related injuries. So this is a group of patients that really needs to get back in the game. They all want to be physically active, and that's a challenge for us when we treat them. So my case is a man, 31-year-old cyclist. He had to suddenly stop for another cyclist and fell. There's a lot of energy in these injuries. They go really fast, so he also had some costal fractures, but the main problem was pain in his left clavicle and shoulder. So he had an acute AC dislocation. And you can see I put some numbers on this X-ray, so I can ask you what kind of dislocation is this. Is this a type three, or four, or five? Most of us use the Rockwood classification, and we would like a classification to tell us both the treatment and the prognosis of the injury. However, there's a lot of papers out there telling us that the inter- and inter-areliability for surgeons classifying AC joint injuries after Rockwood is not very high. So even though we know how it's supposed to be, we cannot do it, and that might be because we have just the AP radiograph. So when you do more radiologic examinations, this is our patients. So is this a type three still, or is this a type four? The definition of the type four is that the clavicle is into the muscle belly, or into the trapezius fascia, and it's stuck there. So it's often very painful. This video is of a type three. I put my finger on the acromion, and you can see that the lateral clavicle is riding over the acromion. The second one, it's obviously a horizontal instability, but it doesn't look like the lateral clavicle is trapped in the muscle belly. So we cannot rely only on the x-rays. We have to do clinical considerations. And for the acute cases, we have to talk to the patients and find out if there's a lot of local pain and swelling and tenderness over the AC joint. And for most of them, it will be in the beginning. However, after a few days, like 10 days, they have much less pain. So the rest of the clinical considerations is more easy to do in a chronical phase, of course, but it's in the beginning we have to decide whether we operate in the acute phase or not. So for the surgical technique, I use a suspensory device with buttons for the acute cases. And in the acute setting, this is then based on the healing of the CC ligaments. However, how long can we do that? For me, it's preferably within two weeks. If it's longer than two weeks, I would like to add a tendon like in the chronic cases. Sometimes you have to open up over the AC joints because it's not possible to reduce. There's a consensus from the ASCA group telling us that x-ray anterior, posterior, and sunca view should be sufficient for diagnosis. I would question that if you want to tell the patients if it's a type four, because that's very difficult to say in an AP view. Non-surgical treatment is recommended initially for most patients, even though I know this is a controversy. I would say that they are chronic after more than two weeks. In this consensus, they ended up with three weeks. There are some tests that you can do also in the acute phase, but we know that when the patient has so much pain, it's difficult to do this diagnostic setup but you should try to get an impression if the lateral clavicle is stuck in the muscle belly. Ultrascopic fixation can be done with cortical botulinum acute cases. And if they are chronic, you need reinforcements with tendon. So here's a lot of stuff to discuss. I know there's a big controversy whether to operate or not for type three, but I would say that there's also many type five that can be treated without surgery. Type four, most of them have so much pain that I would offer them acute surgery, but here's a lot of stuff to discuss. Thank you. Oh, right in front of my face, got it. It's okay, it's not the easiest thing. All right, very good. All right, so we'll talk about SC joint now. And let's see. There we go, disclosures. So this is one of our linebackers about five or six seasons ago. It's number 37, so he's a middle linebacker, kind of over here, you'll see him. I don't know if you can see the cursor. He's chasing this guy right here, and he gets clobbered. So you see he goes down, kind of grabs himself. I'll try to replay that. You can see him again, number 37, so kind of right over here. I guess the cursor's not showing up. So he's coming around the outside to the right, tries to get the quarterback, kind of friendly fire, get hit with a helmet to kind of the front of the chest. So comes running off the field, kind of grabbing this, trying to catch his breath. We examined him on the sideline, kind of saw the injury happen, examined on the sideline. I had immediate suspicion for the injury that he ended up having. We did get x-rays at the stadium, so this was a home game. So we got x-rays at the stadium, which looks suggestive, but kind of, you know, at least in my mind, not definitive. So we brought him right over to the hospital, and you can see we got a CT scan, and he has a posterior steric clavicular joint injury. These CTs, to me, are always a bit breathtaking. First of all, you see there's not much space to begin with, but when that clavicle sits back, you know, kind of a full width there, it's near some pretty scary stuff. Here's what it looked like on the chrono view, where you can see where it's, you know, the clavicle on the non-injured side sits right in joint, and the other one kind of disappears into the back. And then 3D recons are really helpful to view these as well. This guy was about 21 years old at the time of injury. He was a third-year player. The clavicle fysis actually does not ossify until sometimes beyond that. Here we go. So we actually took him to the OR that night. So it was kind of a 3-30 game. Got over to the hospital. We were in the OR by about 8-30 or 9 o'clock. I actually had one of our thoracic surgeons who, thankfully, was coincidentally in doing some sort of cardiac procedure, so he was available. He wasn't in the room, but he was there on site just in case, and we did a closed reduction on him. I have not done very many of these. I've actually done it twice. This is the first time I've done it, so a little bit of angst. But, you know, pulled out the book, read how to do it. So laid him flat on the table under anesthesia, got in fluoroimaging, and used a towel clip, and honestly, really, really gratifying reduction. So it, like, popped right back into place. Felt really great for a moment. And then we decided, well, we should probably take a look at this and make sure it worked. So we actually, and I'll give credit to our chief resident at the time, actually had this idea. I don't do spine surgery, but our spine guys used this O-arm device that was just chilling kind of over in a corner near our OR. I didn't know how to use it, but thankfully the fluorotech did, and so we moved it into place, and we were actually able to get kind of a spin CT kind of in real time, so we didn't have to wake him up and figure out whether it was truly reduced or not. Return to play in these guys is kind of an interesting area. There's not a lot out there. There is one really good paper that was published in kind of a low-level journal by the group at Wash U. So they had a player or two with the Rams when they were still in St. Louis, and then they published on their return to play protocol. I actually called Dr. Warren as well whenever I had questions like this. Russ Warren was my guy because he's seen all this stuff, and he gave me a similar time frame. So for these, if it's a posterior dislocation, closed, reduced, the timeline they suggested was four to six weeks. This guy did return to play at about five weeks. So this game was, I think, our third or fourth game, so he came back and did play the same season. We kind of checked on him week to week to kind of see how things went. I started giving him kind of a gentle push at three to four weeks just to see, and then by five or six weeks I gave him more than gentle push just to make sure it was a stable construct, which it seemed to be. We placed this kind of like piece of armor in the spot, and he was able to get back to play. A couple of additional cases. So what if it's not reducible? The injured patient is actually a girl who wrestles against guys in high school. You can see her walk off here, but she gets kind of pile-driven, like flipped over and slammed by this dude. You'll see her walk off, and she looks pretty stunned. I've got to give her credit because she kind of walked away, but you can tell she's not feeling so great. She was initially seen in an urgent care. They got x-rays of her shoulder. Didn't think much was going on. Sent her for physical therapy, and she eventually got to see me at about a few months after her injury. This is a more chronic situation. Again, CT scan is very helpful to kind of make the diagnosis. You can see some calcification around it as well. It's kind of healing into place. One of our residents was able to use some sort of window to show this. It's just resounding how close this is to all the stuff that we don't want to get near. For her, we did an open procedure. She had a ficeal injury where the fices kind of flipped and was kind of healed, and so we had to basically kind of remove some bone to get the thing mobile and get it reduced. You can see now that we've gotten it kind of cleared up. It's now mobile. For her, I did do a tendon graft reconstruction to the sternum to try to kind of tie it down. This is obviously an injury that's going to take longer to heal. Here's actually this patient. You can see the incision we used there and the post-op X-ray where it's lined up quite well. Her return to play, so to speak, I don't think she went back to wrestling, was about three to four months. Final case, this is a 17-year-old as well. A lot of these are in this age group, as you can imagine. Snowboarding injury landed directly on kind of this was more of an indirect mechanism. We got to him pretty acutely, so here's the incision we used. He did not close-reduce. You can see this thing's kind of stuck deep into the kind of behind the sternum. Again, had a thoracic surgeon available in case, was able to kind of pull it free. You can see the capsular tissue here is still attached to the kind of medial clavicle, but we got it pulled out. Because the FICO cap was still attached to the sternum in this patient, we did a suture-based repair that I think has been published on by Brian Wolfe and his group at University of Iowa. So drill holes with sutures, and then you literally suture it through the cap so the cap is still attached, so the epiphysis is still attached to the sternum. So it provides kind of an anchoring point, so you basically just pass the sutures through that and kind of weave it in, and it holds it in place. All right, so that's what I got on the sternocavicular joint. All right, guys, so we are actually at, well, we're almost at 830, but let's do this. If everybody's willing to hang for maybe an extra five minutes, let's divide up. We can still have time to discuss the cuff repair or the cuff tear cases, and then AC and SC joint cases. We'll spend about eight minutes, and then we'll just bring the groups back together to highlight the debriefing points. All right, this group over here is breaking up. Before you guys leave, would you mind sharing a couple of points? Okay. All right, Sarah's just gonna share a couple points. I know everybody probably has other things to go to. Appreciate you hanging out for a couple extra minutes so that we could spend a little time discussing. But Sarah will share. Yeah, so our primary discussion point was just about Steve's cases and how interesting they were. And luckily I haven't had to deal with that many. But there was some debate whether the posterior dislocation just close reducing it is enough or if we need to open that up and fix the capsule as well. So John, do you have any thoughts on that? Yeah, so we had a little bit of discussion about posterior dislocation. We didn't delve into that. But I think certainly in the acute case, I haven't had that experience. Ours has been more chronic or somewhat delayed presentation in which case we've augmented or reconstructed. So I don't know if other folks have the acute, acute discussion. No. All right, that's a plug for tomorrow afternoon. But no, thank you guys so much for being here. Really appreciate it. Excellent discussion. Enjoy the rest of the meeting too. And for faculty, can we grab a quick picture before you guys leave?

athletic shoulder injuries

shoulder instability

bony Bankart lesion

biceps tenodesis

SLAP repair

rotator cuff repair

AC joint injuries

SC joint injuries

arthroscopic repair

surgical intervention