and then Tiger is going to talk about more of the open or bone loss scenario. So this is a 26-year-old, subluxation events only, so four subluxation events, no dislocation events. He's a paratrooper with the 82nd Airborne. Upcoming deployment in the near future, but otherwise the exam is as you would expect for a isolated anterior instability event with an apprehension relocation. No findings to suggest bone loss in terms of mid-range abduction. No hyperlaxity or posterior exam findings. And you can see his x-rays there, which I don't really suggest anything in terms of bone loss or large hill-sax lesions, but you can see his MRIs here on the sequences below. He does have a bit of an ALPSA lesion and a small hill-sax that you can appreciate. No Hagel or otherwise capsular injury. So this is just a couple of still shots summarizing that. Actually in the interval, kind of before I saw him. Can you hear? Oh, yeah. Thanks, Brent. So before I saw him, or before we went to surgery, he actually had a dislocation event on another airborne event, and then he had these x-rays. So because of these x-rays demonstrating an actual kind of larger hill-sax lesion, we got a CT scan here. You can see the... You want something? So because of the hill-sax lesion, we got the CT scan. You can see here the 3D reconstruction of the glenoid. I put this in just to review how we calculate the glenoid track and on-track, off-track. So if it's on-track, the glenoid track is larger than the hill-sax. So first off, you can draw your perfect circle. You can measure the diameter of the glenoid based on that perfect circle. You can measure your glenoid bone loss, which is in this case the red arrow. And then this is the only math that you need for your glenoid track. And so that math is just 0.83, which is the ratio for the amount of humerus taking out the rotator cuff that articulates with the glenoid. So if you just multiply 0.83 times the diameter, and then just take the bone loss, subtract that from it. So in this equation, 0.83 times the diameter of your glenoid minus 1 for your glenoid bone loss. In this case, that's 25 minus 1, so his glenoid track is 24. And you just need to remember that number. And then it's just one measurement on the hill-sax side. So this is the hill-sax interval. And you can just measure this from the most medial extent of the hill-sax lesion from the infraspinatus. And so in this case, it has a hill-sax lesion. It's on-track. If you wanted to kind of add in what we know from the Pitt group and Albert Lin in terms of distance to dislocation, this would be a near-track lesion because it is within 10 millimeters from being off-track. This is the original glenoid track algorithm for proposed treatment based on the glenoid track. And this is from DiGiacomo's study. So less than 25% glenoid bone loss in an on-track hill-sax lesion. The original recommendation for this was arthroscopic Bankart repair. And so this is kind of the stepwise approach here. This is viewing here, and you can see his large hill-sax lesion. In terms of preparing this, so you can prepare your Bankart first. At least, you know, I like to prepare this first. You can get a good mobilization, elevate down until you see subscapularis. You can go back towards your hill-sax here, preparing your hill-sax for preparation of anchors. And so there's a couple different ways. What I'm showing here is actually tying knots, but I think you can actually do this more effectively. So you can place your anchors first. This is a double-loaded. I'm showing one, but we placed two anchors here in this hill-sax lesion. And you can place your cannula just outside the capsule and grab those sutures passing individually through the capsule at different points. And you can do that without worrying about intertangling your sutures because your cannula is just outside. You can also do this with a knotless system. I think Nick showed this nicely, and that's actually very effective. This is a nice way to do when you have your Bankart repair. So you go back to your Bankart repair. I don't tie or fix the hill-sax lesion because that can block you out. But when you do your Bankart repair, one of the nice things about using this system is that you can keep those sutures if you're using a knotless system and then go back and re-tension them. I think you can see here, even though I thought I had good tension, once I passed them, you can see you get some more tension after you go back. So each subsequent pass, I think you probably lose a little bit of tension. You can gain a little bit more if you keep those and go back. And then you can finally, last case, at the end, go back and tie your sutures. Or if you're using a knotless system, you can go back and do your final tensioning on your graft. And I just put in one word on rehabilitation as potentially a discussion item for the tables because I think we have a multidisciplinary audience here. There's a lot to learn, I think, and we don't do a good job of how we guide our rehab following instability patients. There's certainly a lot that's time-based, a lot where we say it's an X amount of time. But in reality, we should be thinking about this probably in a phase-based transition. So there's a lot of factors that go into that from psychological readiness in terms of kinesiophobia, range of motion, strength, and then more of a functional stability. So this is just some of the work that I give credit to for our physical therapist at Duke, and this is some of the return-to-play testing that's been implemented here and certainly a lot to learn from that. So just some proposed questions, I think, for the table. I think we want to have Tiger do his talk.

anterior instability

ALPSA lesion

hill-sacks lesion

arthroscopic Bankart repair

rehabilitation